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MANUAL 


OP 


DENTAL  SURGERY  AND  PATHOLOGY. 


BY 

ALFRED  COLEMAN,  L.R.C.R, 

F.R.C.S.  EXAM.   L.D.S.,  ETC., 

SENIOR  DBSTAL  fiURUEON  AND  LECTURKR  ON  DENTAL  SUROERY  TO  ST.  B  ARTHOLO.M  U  VV' 

HOJJPITAI,  ;  SENIOR  DENTAL  SURGEON  AND  LECTURER  ON  DENTAL  SUROERV  TO 

THE  DENTAL  HOSPITAL  OF  LONDON  ;  ME.MBER  OF  BOARD  OF  EXAMINERS 

IN  DENTAL  SURGERT,  ROYAL  COLLEGE  OF  SURGEONS  ;  FORMERLY 

PRESIDENT  ODONTOLOGICAL  SOCIETY  OF  GREAT  BRITAIN. 


THOROUGHLY  REVISED  AND  ADAPTED  TO  THE  USE  OF  AMERICAN 
STUDENTS  AND  PRACTITIONERS. 


BY 

THOMAS  C.  STELLWAGEN,  MA.,M.D.,D.D.S. 

PROFESSOR  OF  PHYSIOLOGY  AT  THE  PHILADELPHIA  DENTAL  COLLEGE. 


P  H  I  L  A  D  E  L  P  II I  A : 
HENRY     C.    LEA'S     SON& 
1882. 


CO 


Entered  according  to  Act  of  Congress,  in  the  year  1882,  by 

HENRY   C.   LEA'S    SON  &   CO., 

ill  the  Office  of  tlie  Librarian  of  Congress.     All  rights  reserved. 


COLLINS,     I'  K  I  N  r  E  K 


PREFACE  TO  THE  AMERICAN  EDITION. 


In  introducing  Mr.  Coleman's  3Linual  of  Dental  Surgery  raid 
Pathology  to  the  American  profession  the  [iretiice  furnished 
by  tlie  antlior  rendei's  it  nnnecessarv  for  the  editor  to  say  more 
tlian  will  suffice  to  indicate  very  briefly  his  own  share  in  its 
preparation  for  publication.  The  care  which  Mr.  Coleman  has 
bestowed  upon  liis  work  has  left  but  comparatively  few 
additions  to  be  supplied. 

In  no  direction,  perhaps,  has  the  ingenuity  of  the  American 
mind  been  more  actively  exercised  than  in  the  [iroductlon  of 
an  immense  variety  of  instruments  for  the  use  of  the  dental 
surgeon.  The  difficulty  experienced  by  the  student  in  making 
proper  selections  from  these  lias  seemed  to  justify  the  insertion 
of  a  special  chai)ter  devoted  to  their  choice. 

A  chapter  on  the  present  greatly  improved  methods  of  crown- 
ing teeth,  has  been  added  in  view  of  this  being  generally 
performed  by  the  operative  dentist,  and  because  of  its  bearing 
U[>oii  the  efforts  now  made  for  the  ])reservation  of  the  natural 
teeth  and  roots.  Throughout  the  work  have  been  inserted 
many  notes  descriptive  of  certain  modes  of  treatment  demanded 
by  the  peculiarities  of  our  climate,  or  indicative  of  the  latest 
and  most  approved  systems  of  operating  adopted  on  this  Con- 
tinent. 

To  accommodate  the  one  hundred  and  twelve  added  illustra- 
tions, delineating  some  three  hundred  and  twenty  instruments 
and  appliances,  an  increase  in  the  size  of  the  page   has  been 


iv  PREFACE    TO    THE    AMERICAN    EDITION. 

rendered  neeessnr}'.  The  original  text  has  been  preserved  with 
but  few  alterations,  and  all  additions,  amounting  to  about 
f)ne  hundred  pages,  have  been  distinguished  b}^  inclusion  in 
brackets  [     ]. 

In  conclusion,  the  editor  desires  to  acknowledge  his  indebt- 
edness to  Drs.  James  W.  White  and  Wilbur  F.  Litch  for  their 
assistance  in  [)reparing  this  work  for  publication. 

No.  1637  Chestnut  Street,  Philadelphia, 
February,  1882. 


PREFACE. 


If  illustration  Avere  wanted  to  show  that  immense  advances 
have  been  made  in  tlie  science  and  practice  of  Dental  Surgery 
during  the  last  tliirty  or  forty  years,  no  better  one  could  be  fur- 
nished than  the  circumstance  that  most  of  the  leading  works 
on  the  subject  at  the  commencement  of  that  period  comjire- 
hended,  and  within  very  modest  limits,  all  its  branches,  viz. : 
Dental  Anatomy,  Physiology,  Surgery,  Pathology,  Therapeu- 
tics, Materia  Medica,  and  often  even  Mechanics. 

The  establishment,  in  this  and  several  other  countries,  of  a 
defined  and  systematic  course  for  the  student  of  Dental  Science, 
including  distinct  courses  of  lectures  u[)on  Dental  Anatomy  and 
Physiology,  Dental  Surgery  and  Pathology,  and  Dental  Me- 
chanics, Ijas,  perhajis  more  than  anything  else,  led  to  a  demand 
for  sejiarate  and  more  complete  treatises  on  these  several  depart- 
ments. 

In  some  of  these  subjects  this  want  has  been  coujpletely  sup- 
plied, and  the  Dental  Student  can  have  nothing  more  to  desire 
than  the  recent  admirable  treatise  on  Dental  Anatomy,  Human 
and  Comparative,  wliich  has  appeared  from  the  hands  of  my 
talented  colleague,  Mr.  C.  S.  Tomes. 

Another  subject,  viz..  Dental  Mechanics,  has  been  separately 
and  successfully  treated  upon  in  the  manual  of  Mr.  Oakley 
Coles,  and  the  English  student  desirous  of  fuller  information 
can  obtain  the  same  in  his  own  language,  in  "  A  Practical 
Treatise  on  Mechanical  Dentistry,"  by  Dr.  Joseph  Richardsox, 
of  Ohio,  U.  S. 


VI  PREFACE. 

On  the  subject  of  Dental  Surgery— and  to  my  lot  has  follen 
the  privilege  of  lecturing  tliereon  at  the  largest  Medical  School 
in  London  consecutivel}'  for  fifteen  years — it  can  hardly  be  said 
that  any  work  perfectl}-  suitable  as  a  text-book  has  yet  been 
produced.  The  excellent  works  of  Mr.  John  Tomes,  and  of  that 
gentleman  in  conjunction  with  Mr.  C.  S.  Tomes,  which  have 
been  so  much  employed  and  valued  for  that  pur[)Ose,  include 
also  Human  Dental  Anatomy  and  Physiology,  which  by  many, 
and  especially  the  general  medical  student,  whose  requirements 
I  have  endeavored  to  bear  in  mind,  may  not  be  needed.  On  the 
other  hand^  Mr.  Salter's  much  appreciated  work,  though  chiefly 
confined  to  Dental  Pathology  and  Surgery,  is,  as  the  author 
states,  "a  digested  collection  of  all  my  previous  essays  and 
papers,  arranged  in  the  foi-m  of  chapters;  and  several  more 
chapters  have  been  added  to  }>reviously  published  matter," 
rather  than  a  systematic  treatise  upon  the  subject. 
*  It  is  therefore  hoped  that  the  present  work  may  supply  a 
want  which  I  believe  to  exist,  although  I  cannot  venture  to 
presume  that  it  will  satisfy  the  requirements  of  the  student  as 
fully  as  the  work  of  Mr.  C.  S.  Tomes  accomplishes  its  object; 
nevertheless,  I  trust  that  the  large  amount  of  experience  which 
has  fallen  to  my  lot,  as  a  consequence  of  holding  hospital  ap- 
pointments for  nearly  a  quarter  of  a  century,  niay  not  have 
been  lost  upon  me,  and  that  the  results  may  in  these  [tages  be 
rendered  profitable  to  others. 

One  of  my  chief  desires  has  been  to  make  the  work  as  sys- 
tennitic  as  possible,  associating  under  the  same  head  a  variety 
of  subjects  wiiich  bear  upon  one  another,  rather  than  isolating 
them  under  distinct  chapters,  and  to  avoid  as  much  as  possible 
the  recording  of  cases,  even  though  rare  and  interesting,  which 
could  not  be  considered  appro[)riately  under  any  [)roper  classi- 
lication. 

In  attempting  to  make  the  work  a  jiractical  treatise,  I  have 
laid  njyself  under  heavy  obligation  to  those  who  have  so  kindly 


PREFACE.  Vll 

assisted  me.  To  Mr.  C.  S.  Rouers,  the  demonstrator  at  the 
Dental  Hospital  of  London,  my  best  thanks  are  due  for  the 
chief  contents  of  the  pages  devoted  to  the  descri^jtion  of  tillino; 
with  cohesive  gold.  To  Messrs.  C.  Ash  &  Sons,  of  London,  my 
warmest  thanks  are  due  for  the  valuable  loan  of  some  250  illus- 
trations of  instruments,  appliances,  etc. ;  as  they  are  also  to  the 
eminent  practitioners  by  whom  many  of  the  latter  were  in- 
vented, and  whose  iiiimes  I  have  endeavored  always  to  insert 
in  the  foot-notes  referring  to  them.  To  the  Council  of  the 
Odontological  Society  I  am  indebted  for  permission  to  copy  the 
illustrations  which  have  appeared  m  my  papers  published  in 
their  "  Transactions."  To  Mr.  iSToBLE  Smith  I  owe  much  for 
tlie  pains  and  skill  that  he  has  besto\ved  upon  the  original 
woodcuts  which  illustrate  the  work.  To  very  many  authors  I 
am  largely  indebted  for  material  collected  from  their  works, 
which,  I  fear,  I  have  on  some  occasions,  omitted  to  acknowl- 
edge. Finally,  I  am  under  heavy  obligations  to  Mr.  E.  Har- 
rison, barrister-at-law,  for  his  kindness  in  undertaking  the 
tedious  and  uninteresting  work  of  revising  my  pages. 

A.  C. 


CONTENTS. 


CHAPTER    I. 

PAGE 

The  First  Dentition.  Order  and  Periods  of  Eruption.  Xorm'il  and  Ab- 
normal Conditions  occurring  during  Teetliing  17 

CHAPTER    II. 

Irregularities  in  the  Temporary  Teeth.  Diseases  of  the  Temporary  Teeth. 
The  Second  Dentition •       38 

CHAPTER    III. 

Irregularities  in  the  Permanent  Teeth,  in  Size,  in  Form  (Odontomes),  in 
Number,  in  Position — Class  I.  Accidental  and  Avoidable  (Fractures  of 
the  Jaws) 54 

CHAPTER    lY. 

Irregulai-itiesin  the  Permanent  Teeth  in  Position,  continued — Class  II.  Con- 
genital and  Unavoidable        ...  .....       88 

CHAPTER    V.       • 
Injuries  to  the  teeth.     Concussion,  Dislocation,  Fracture  .  .         .  .108 

CHAPTER    YI. 

Dental   Caries.     Description  of  the    Disease,  Microscopical    Appearances. 

Theories  of  Dental  Caries     .         .  .  .  .         .  .         .  .114 

[  C  H  A  P  T  E  R    Y  1 1 . 
Selection  of  Instruments  .........     134] 

CHAPTER    YIII. 

Treatment  of  Dental  Caries  (Anticipation  and  Prevention),  by  Excision, 
by  Stopping,  Filling,  or  Plugging.  Pi'eparation  of  the  tooth  for  Filling, 
Materials  Employed,  and  the  Processes  of  their  Manipulation         .  .      IGl 


X  CONTENTS. 

CHAPTER    IX. 

PAOE 

Treatiiu'iit   of  Dental  Carios,   coiitimu'd.       Dllliciilties  and    Complications 

UK-t  with  in  the  OiK-ratlon  of  Filling  Tc-etli    ......      21(; 

C  H  A  P  T  I<:  Ft    X  . 

Pi-rioilontitis.      Synijitoms,  Pathology,  and  Treatment        ....      235 

CHAPTER    XI. 
Xeeroiis.     Absorption  of  Permanent  Teeth.      Exostosis    ....      2.')0 

[CHAPTER    XII. 
Fitting  Artificial  Crowns  to  Roots  of  Natm-il  Teeth         ....     257] 

CHAPTER    XIII. 

Extraction  of  Teeth,  General  Directions.     Extraction  of  Individual  Teeth     264 

CHAPTER    XIV. 

Extraction  of  Roots  of  Teeth,  with  the  Forceps,  with  the  Elevator,  etc. 
Extraction  of  Temporary  Teeth    ........     290 

CHAPTER    XV. 

Difficulties  and  Complications  occurring  in  Extraction,  due  to  Malformed 
Teeth,  Contraction  of  the  Jaws,  Impacted  Teeth,  Alveolar  Hemon-hage, 
etc 302 

C  H  iV  P  T  E  R    XVI. 
Aneesthesia,  History  of,  by  Nitrous  Oxide  Gas,  by  Ether,  by  Chloroform  .     3l;> 

CHAPTER    XVII. 

Tiie  Replantation  and  Transplantation  of  Teeth  .....      345 

CHAPTER    XVIII. 

Congestion  of  the   Gums.      Salivary  Calculus.      Ulcerations  of  the  Gum. 

Necrosis  of  the  Jaws     ..........     Sii'.i 

V  11  A  PTER    XIX. 
Cicatrices  closinif  the  Jaws  ........  37<» 


CONTENTS.  XI 

CHAPTER    XX. 

PAOE 

Tumors  of  the  (Jiiins  mid  upuu  the  Jaws  .  .  .  .  .  .  .      372 

CHAP  T  J-:  11    XXI. 

Uuntigerous  Cysts     .  .  .  .  .  .  .  .  .         .     .379 

C  H  A  r  T  E  R    X  X  I  I . 

Diseases  of  the  Antrum    ..........     38C 

C  H  A  P  T  E  R    XXIII. 
Nervous  and  Mnscuhir  Affections  dependent  upon  Dental  Irritation    .  .     391 

INDEX 399 


LIST  OF  ILLUSTRATIONS. 


FIO. 
1. 

2. 
3. 

4, 
5. 

6. 


[9. 
10. 

[11 
12. 

13. 
14. 

15. 
16. 
17. 
18. 
19. 
20. 

21. 

22. 
23. 

24. 
25. 
26. 
27. 

[28, 

29. 
30. 


The  temporary  teeth  of  the  right  side  in  the  upper  and  lower  jaws 
Dental  pocket  hineet  ....... 

Upper  secondary  temporary  molar  with  four  fangs 

Lower  second  temporary  molar  with  three  fangs 

Gemination  of  a  temporary  lateral  incisor  and  cuspidatus  of  the  lowe 

jaw     .  .  .  .  .  . 

Upper  jaw  of  a  child  in  which  the  lateral  incisors  arc  absent     . 

Lower  jaw  of  a  cliild  in  which  all  the  incisors  are  absent 

Upper  jaw  containing  a  supernumerary  lateral  incisor  on  the  right  sidi 

Protrusion  of  the  superior  incisors  (Dental  Cosmos) 

Chin  retractor  as  applied  ..... 

Another  ibrm  of  chin  retractor  .... 

Uj^per  jaw  with  portions  of  the  roots  of  temporary  central  incisor: 

exposed  ....... 

Lower  jaw  with  one  root  fully  and  one  partially  exposed 

Upper  maxilla  with  portions  cut  away  to  exhibit  the  developing  per 

manent  teeth  ...... 

Upper  permanent  teeth  of  the  left  side 
Lower  permanent  teeth  of  the  right  side 
Permanent  teeth  of  unusually  large  dimensions 
Permanent  teeth  of  unusually  small  dimensions 
Honeycombed  teeth  of  the  upper  jaw    .... 

Syphilitic  teeth  in  upper  and  lower  jaws  as  they  appear  when  recently 

erupted  ....... 

Syphilitic  teeth  in  upper  and  lower  jaws  which  have  been  erupted  some 

time   .  ... 

Supernumerary  permanent  tooth  of  the  most  common  type 
Supernumerary  tooth  not  unirecpiently  met  with  in  the  region  of  the 

upper  central  incisors  ..... 

Three  specimens  of  gemination  .... 

Supernumerary  teeth  in  the  upper  jaw  of  a  }  outh 
Su])ernumerary  bicuspid  of  the  upper  jaw,  riglit  side  . 
L^pper  jaw  in  which  the  lateral  incisors  have  not  been  erujited 
The  positions  of  the  developing  permanent  teetli  and  the  fangs  of  the 

temporary  teeth  (White)         ..... 
Side  view  of  the  jaw  of  a  cliild  with  permanent  teetli  forming 
Lower  jaw  in  which  tlu;  permanent  central  incisors  have  been  crupti'd 

behind  the  temporary  central  incisors  .... 


PACE 

19 
26 
39 
39 

39 
40 
40 
40 

40] 

41 

41] 

42 
42 

45 
49 
50 
54 
54 


57 
58 

58 
58 
61 
61 
62 

64] 
65 

67 


XIV  LIST    OF    ILLUSTRATIONS. 

no.  PAOB 

ol.   Tlie  condition  toriiu'd  partially  nndcrliung         .  .  ,  .67 

[32.  Improssion  c'\ip  for  wax,  upper  jaw  ....'.  68] 
[33.  Impression  rup  lor  wax,  lower  jaw  .....  68] 
[34.   Impression  cup  for  plaster,  lower  jaw  .  ....      G9] 

[35.  Impression  cup  for  plaster,  upper  jaw  ....      69] 

SG.   Plate  adapted  for  pressing  out  the  central  incisors  .  .  .70 

37.  Plate  adapted  for  drawing  inwards  the  front  teeth  of  the  upper  jaAV     .        73 

38.  Right  central   incisor  of    the  upper  jaw   erupted  at  an  angle  to  the 

dental  arch  from  want  of  space  .  .  .  ,  .73 

[39.  The  half  hitch  .  .  .  .  .  .  .'75] 

[40.  The  square  knot  .  .  .  .  .  ,  .7.5] 

[41.  The  surgeon's  knot       .......      75] 

[42.  The  clove  hitch  .  .  .  .  .  .  .75] 

[43.  Drawing  a  tooth  forward  into  the  arch  by  an  elastic  ligature   .  .      75] 

[44.   Rings  cut  from  rubber  tubing  ......      75] 

[45.  McQuillen's  cap  to  prevent  occlusion  of  the  teeth  (Dental  Cosmos)  .  7G] 
[46.  McQuillen's  bar  for  drawing  teeth  forward  (Dental  Cosmos)  .      76] 

[4  7.   A  method  of  drawing  a  tooth  into  position   by  an  elastic   ligature 

(Dental  Cosmos)        .  .  .  .  .  .  -7'] 

[48.   Flagg's  method  of  tying  ligature  for  torsion    .  .  .  •      '^'] 

[49.   A  case  of  torsion  and  retraction  of  central  incisoi's  by  a  plate  with  pins 

and  elastic  ligatures  (Dental  Cosmos)  ....      78] 

[50.  Guilford's  torsion  apparatus     ......     79] 

[51.  Mode  of  applying  the  above    ......      79] 

[52.  Represents  position  of  teeth  before  treatment  by  Guilford's  apparatus  8(»] 
[53.   Represents  position  of  teeth  after  treatment  by  the  same         .  .81] 

[54.   Represents  peculiar  formation  of  teeth  in  Avhich  the  same  treatment 

can  be  followed  .  .  .  ,.  .  .  .81] 

55.   Fracture  of  the  lower  jaw  treated  by  means  of  a  metallic  cap  .       83 

5C.   A'ertical  fracture  of  the  lower  jaw  between  the  left  euspidttus  and  first 

bicus]>id  .  .  .  .  .  .  .  .84 

57.  Ada]jtation  of  the  fractured  parts  l)y  a  plaster  cut  .  .  .84 

58.  Gunning's  interdental  splint  for  fractures  of  either  jaw  .  .  85 
.^9.   Hammond's  splint  in  situ           .              .              .              .              .              .86 

60.  Well-developed' upper  jaw  in  a  youth  aged  about  twelve  years  .       89 

61.  luijK'rfectly-develojjcd    up])er   jaw  with  irregular  dental  arch.     The 

lateral  incisors  art;  bitt«'n  over  by  the  lower  ciispiduti  .  .        90 

62.  Imf)erfcctly-develo])ed   up])er  jaw,  and  when;  the  dental  arch   assumes 

the  V-shaped  form      .  .  .  .  .  .  .91 

63.  Imperfectly  and  ill-developed   u])per  jaw,  a  case  suital^lc  for  trt'atmcnt 

by  expa)ision  of  the  dental  arch         .  .  .  .  .92 

64.  CofTin's  method  for  expanding  the  contracted  dental  arch  liy  means  of 

a  divided  ))late  and  sjiring  formed  of  pianoforte  wire,  the  back  teeth 
heing  capj)e<l  .  .  .  .  .  .  .94 

65.  Contractcrl  dental  arch  .  .  .  .  .  .  .94 

CG.   The  expansion  of  a  V-shaped  arch  by  means  of  Coffin's  jjlate  .  .        94 


LIST    OF    ILLUSTRATIONS.  XV 

PIO.  PAOE 

67.  The  jack-screw,  three  sizes    ......  ri4 

68.  Appearance  after  treatment  by  expansion       ....  <)!) 

69.  Result  of  an  early  removal  of  all  of  the  bicuspids  in  tiie  njjjier  jaw  .  f)7 

70.  Result  of  an  early  removal  of  three  bicuspids  in  the  lower  jaw  .  97 
[71.   Deformity  from  too  early  extraction  of  sixth  year  molar  (Dental 

Cosmos)        ........        98] 

[72.   J)eformity  from  extraction  of  sixth  year  molar  after  the  eruption  of 

tlie  twelfth  year  molar  (Dental  Cosmos)      ....       98] 
7.1,  74.  Cases  in  which  the  removal  of  the  first  molars  from  each  jaw  would 

be  beneficial  .  .  .  .  .  .  .100 

75.  70.   Cases  in  which  the  removal  of  the  first  bicuspids  of  the  upper  jaw 

only  is  advisable       .......        liKi 

77,  78.  Before  and  after  removal  of  the  upper  first  bicuspids  only  .        101 

79,  80.  Cases  in  which  the  removal  of  the  two  second  bicuspids  from  the 
upper  and  the  right  lateral  incisor  from  the  lower  jaw  is  to  be 
recommended    .  .  .  .  .  .  .101 

81.  Results  of  an  early  removal  of  the  temporary  molars  in  an  ill-devel- 

oped lower  jaw  .  .  .  .  .  .  .10,3 

82,  83.   Comparative  advance  of  the  first  permanent  molars  after  the  shed- 

ding of  the  temporary  molars  .....        lO.'j 

84.  Ill-result  of  removing  the  temporary  incisors  and  cuspidati  to  give 

room  for  the  permanent  incisors      .  .  .  .  .106 

85.  Treatment  by  removing  from  the  lower  jaw  the  temporary  teeth  onlv 

as  their  successors  appear    .              .              .              .              .  .106 

[85a.  Bands  for  protecting  teeth,  to  be  moved  by  jack-screws     .  .      107] 

86.  Impacted  fracture  in  an  upper  incisor  tooth  .              .             .  .112 

87.  Microscopic  section  of  tooth  affected  with  caries         .              .  .115 

88.  The  tobacco- pipe- stem  appearance  of  the  chalky  decay  (Tomes)  .  117 
[89.  Translucent  zone  in  a  tooth  that  had  been  filled  with  gold  .  .117] 
[90.  Cross-section  of  carious  dentine  magnified  1000  diameters  (Abbott)     118] 

91.  Fracture  of  dentine  covered  with  leptothrix  and  micrococci  .  .       119 

92.  Cuspidatus  of  the  lower  jaw  worn  on  its  lingual  surface  by  the  fric- 

tion of  a  plate  .  .  .  .  .  .  .130 

[93.  New  socket  handles                ......     135] 

[94.  Student's  instrument  case     .             .              .             .              .             .      136] 

[95.  Scalers — Forbes'  gouge         .              .              .              .              .              .137] 

[96.  Scaler,  to  be  sharpened  on  both  edges  for  gum  lancet           .              .     138] 

[97.  Combined- foil  carrier  and  plugger     .....      138] 

[98.  Curved  scissors           .              .              .              .              .             .             .138] 

[99,  100.  Magnifying  mouth-mirrors          .....      139] 

[101.  Glass  syringe               .......      139] 

[102.  Jack's  enamel  chisels             ......      140] 

[103.  Dental  files   .              .              .             .              .             .             .             .140] 

[104.  D.  D.  Smith's  plug  finisher                .....     140] 

[105.  Kffiber  saw  frame      .              .              .             .             .              .              .141] 

[106.  Scoops            ........      142] 

[107.  Hatchets        ........      143] 


XVJ 


LIST    OF    ILLUSTRATIONS, 


FIO. 

;io8 
;io9, 
;iio 
;iii 
;ii2 
11  r> 

114 
'IIG 

;ii7 
;ii8 
;ii9 
;f2o, 

il21, 

;i22 

123, 

;i24, 
;i25. 
;i2c, 

127. 

;i28. 
;i29. 
;i3o. 

"131, 

;i32. 

"133. 
134, 


135 

;i3G 

137 

;i38 
;i39 
;i4o 
;i4i 
;i42 
;i43 

144 
145. 

14(;, 

150. 
151. 
152. 

[15.-^, 


.  Hoes  ...... 

,  Diamond-shiipod  points         .... 

,   Auger  drill.  —  Kouiid  burs.  —  Odd  or  acorn  burs 

.  AVhcei  burs  ...... 

.   Oval  burs      ...... 

,   I'almcr's  norvc-canal  instruments     . 

,115.  Retaining-point  drills,  spade,  and  spear-points 

,   Stump  files  and  corundum  wheels,  for  pivoting 

.  Round  burs  ...... 

,  "Wheel  burs  ...... 

,  Inverted-cone  burs    ..... 

,  Fissure  burs  ...... 

,  Pointed  fissure  drills  .... 

,  Spear-pointed  drills  .... 

,  Five-sided  drills        ..... 

,   Fine-cut  round  burs  ..... 

Fine-cut  pear-shaped  burs     .... 
,   Sugar-loaf  drills        ..... 

Dr.  Holmes'  engine-bit  oiler 
,   Screw-head  mandrels  with  and  without  .shoulder 

Northrop' s  corundum  points 

Arkansas-stone  polisliing  points. — Diamond-disk  wheel 
,  Flexible  rubber  disk  for  polishing  j)roximate  surfaces 
,  Diamond  disk  ibr  separating  teeth    . 

ICUis'  pluggers. — New  York  set  of  pluggers. — Lord's  pluiriiers  and 

burnishers     ...... 

Jack's  matrix. — Set  of  Jack's  matrices. — Matrix  plugger,  magnifiec 

— Set  of  matrix  pluggers. — Pliers  for  adjusting  matrices. — Sectiona 

views  of  cavities  on  ])roximate  surfaces 

Hand  or  mallet  pluggers. — S.  S.  W.  burnishers. — Darby's  burnishers 

— Engine  burnishers  .... 

Flagg's  condensing  forceps. — Weston's  amalgam  pluggers 

Palmer's  metal  tube  with  lead  filling,  for  nudlet-head 
.   Cutting  pliers  ..... 

,  Wedge  pliers.  Palmer's  pattern 

Forms  of  enamel  chisels  or  cutters  . 
,  Paraboloid  and  gouge  chisels  of  Jack  and  Forbes    . 
,  The  S.  S.  Wliite  dental  engine 

,  The  S.  S.  White  water  motor  apjjlicd  to  the  dental  engine 
,  Corundum  points  used  with  the  denial  engine 
Typical  form  of  a  cavity  when  prepared  for  receiving  a  filling 
14  7,  148,  149.   Various  forms  of  mandrel  or  handpiece  for  the  denta 

engine  ...... 

Flexiljle  Jn<lia-iul)l)er  syringe 

Rogers'  saliva-ejectf)r  .... 

Sectional  view  of  Fisk's  ejector 

Puncli  for  makinjf  holes  in  the  rubl)er-<lam  . 


LIST    OF    ILLUSTRATIONS. 


XVll 


I'lO. 

154.  Silvered  glass  inoutli-iniiTor,  with  ball-and-socket  joint 

155.  Instninient  for  aj)[)lvinu;  the  eofler-dam 

[15G.  Clamp  forcejjs  (Bownian  Allen)       .... 
[157.  Tees'  rubber-dam  clamps      ..... 

158.  Method  of  applying  the  rubber-dam  (Elliott) 

159.  The  rubber-dam  and  clamp  2;i  si7»     .... 

[160.  Cogswell's  rubber-dam  holders  .... 

[161.   Shape  for  rubber-dam  to  admit  of  easy  respiration  . 

162.   Owen's  dental  table    ...... 

[163.  The  Morrison  bracket  ..... 

[164.  Allan's  pattern  of  table  for  the  bracket 

[165.   Houghton's  steel  spatula  for  finishing  off  gutta-percha  and  amalgam 

fillings  ....... 

[166.   Flagg's  lamp  and  Avater-bath  .... 

167.  McAdams' combined  spatula  and  stopjjcr 

168.  Rowney's  agate  burnisher       ..... 

169.  Polished  steel  burnishers  of  various  forms 
1  70.  Useful  forms  of  amalgam  stoppers      .... 

171.  Iron  spoon  or  ladle  with  wooden  handle 

172.  Pestle  and  mortar  for  breaking  inp  the  copper  amalgam  when  heated 

173.  The  mercury  drop-bottle         ..... 

174.  Balance  for  weighing   out  Fletcher's  fdings  and  mercury  in  prope 

proportions  ....... 

175.  Fletcher's  mixing-tube  for  shaking  together  filings  and  mefcury 

176.  Fletcher's  mortar  and  plunger  for  compressing  platinum  amalgam 

into  disks      ....... 

17  7.  Pinney's  thin  metal  clamp  for  forming  a  temporary  sustaining  wall 
1  78.   Arrangement  for  giving  sujiport  to  an  amalgam  filling  upon  an  almo. 

flat  surface   ....... 

179.  The  Wilkerson  operating  chair  .... 

180.  Lyon's  adjustable  stool  ..... 

181.  Scissors  for  dividing  the  sheets  of  gold  and  other  foil 

182.  Knife  for  folding  gold  or  other  foil     .... 

183.  Tweezers  of  suitable  form  to  be  employed  in  plugging  teeth 

184.  Hand  mallet  of  hard  wood  filled  with  lead     . 

185.  Automatic  mallet  (Snow  and  Lewis) 

[186.   Flagg's  condensing  forceps    ..... 

187.  File-carrier  for  filling  teeth  at  the  back  of  the  mouth 

188.  Steel  holder  for  Arkansas  or  corundum  points 

189.  Harding's  tape-can'ier  with   steel-sjiring  ratchet  for  tightening  the 

tape  ....... 

1 90.  Method  of  taking  up  gold  foil  for  insertion  into  a  cavity  on  the  plan 

of  stars  or  strips       ...... 

191.  Tomes'  foil  roller  for  making  cylinders  in  foil 

192.  Form  of  gold  foil  prepared  in  cylinders 

193.  Form  of  gold  foil  prepared  in  blocks  with  parallel  layers 

1 94.  Spade  drills     ....... 


PAOE 

174 

176 

176] 

176] 

177 

178 

178] 

178] 

179 

180] 

181] 

181] 
182] 
184 
184 
187 
187 
189 
189 
190 

190 
191 

191 

192 

192 
194 
195 
195 
196 
196 
197 
197 
198] 
199 
199 

200 

200 
201 
201 
201 

205 


xvm 


LIST    OF    ILLUSTRATIONS. 


195.  Sbnllow  and  spoon-shaped  cavity  in  a  cuspidatus  tooth 

196.  Spirit-lamp  and  tray  for  heating  (annealing)  gold  foil 

197.  Spirit-lamp  suitable  for  heating  (annealing)  gold  foil 

198.  llich's  tweezers  for  carrying  cohesive  foil  to  the  retaining  points  or 

grooves         ...... 

199.  Three  forms  of  plugger  for  condensing  cohesive  foil 

200.  Kirby's  pneumatic  mallet       .... 

201.  Power's  mallet  .  .  . 

202.  Three  forms  of  bit  for  Power's  engine  mallet 

203.  Electro-magnetic  mallet  .... 

204.  Corundum  wheel  to  fit  the  mandrel  of  a  dental  engine 

205.  Corundum  wheel  with  Ives'  tongue  and  cheek  protector 

206.  Moffat's  hot-air  syringe  .  .  .  . 

207.  Cavity  in  a  bicuspid  tooth   prepared  for  filling  by  the  combined 

process  ...... 

[208.  Fissure  burs  ...... 

[209.   Oval  burs      .  .  .  . 

[210.  Adjustment  of  Jack's  matrices 

211.  Jarvis'  screw  separators  .... 

212.  Barbed  nerve-extractor  made  of  soft  steel  for  removal  of  dental  jxdps 

213.  The  galvanic  cautery  .... 

214.  A  lancet  of  convenient  form  for  excising  a  polypus    . 
21.5.  Instruments  for  removing  the  disorganized  contents  of  a  pulp-cavity 

216.  Pluggers  of  delicate  form  for  filling  the  fang-cavities  with  fo 

217.  Pulp-cavity  drills  to  be  employed  with  the  dental  engine 
[218.   Cast  of  mouth  showing  a  cystic  tumor 
[219.  The  same  after  treatment      .... 

220.  Passage  of  the  white  blood-corpuscles  through  the  walls  of  a  blood 

vessel  ...... 

221.  Farrar's  alveolar-abscess  syringe 
[222.   Hot-air  syringe  ..... 

223.  Unerupted  wisdom  tooth,  causing  absorption  of  the  approximal  sur 

face  of  a  second  molar  .... 

224.  Absorption  of  the  roots  of  three  permanent  incisor  teeth 

225.  Cases  of  hyperostosis  and  exostosis  in  the  i'angs  of  teeth 
[226.  Pivot  files  and  wheels  .... 
[227.  Gates-Bonwill  crowns            .... 
[228.  The  teeth  of  the  left  side  of  the  mouth 

229.  Key  instrument  for  extracting  teeth    . 

230.  Forceps  for  extracting  upper  incisor  and  cnspidati  teeth 
[231.   Superior  incisor  forceps         .... 
[232.  Inferior  incisor,  canine  and  bicuspid  forceps 
[233.   Upper  molar  forceps  for  either  side  . 
[234.   Lower  molar  forceps  for  either  side  . 
[235.   Hoot  forceps  ..... 
[2.'iC.    Upper  molar  and  wisdom  teeth  forceps 
[237.   Forceps  for  cutting  out  the  roots        . 


PAGE 

205 
206 
206 

207 
207 
207 
207 
208 
209 
209 
210 
210 

213 

213] 

213] 

214] 

217 

225 

225 

225 

228 

228 

231 

237] 

237] 

239 

247 

252] 

253 
2.53 
254 

258] 
202] 
266] 
268 
269 
271] 
271] 
271] 
272] 
272] 
272] 
273] 


LIST    OF    ILLUSTRATIONS.  XlX 

FIO.  PAOK 

[238.  Right  and  loft  upper  mohiv  forceps  .....  274] 

[239.   Root  forceps               .......  274] 

[240.   Right  and  left  upper  molar  forceps  .....  27o] 

[241.  Lower  molar  forceps,  either  side      .....  27.j] 

[242.  Cutting  forceps          .......  270] 

[243.  Lateral  incisor  forceps           ......  27G] 

[244.  Lower  incisor  and  root  forceps  .  .  .  .  .276] 

245.  Transverse  sections  of  the  teeth  of  the  upper  jaw  made  at  their  necks  27fS 

24G.   Transverse  sections  of  the  teeth  of  the  lower  jaw  made  at  their  necks  278 

247.  Central  incisor  of  up])er  jaw,  front  and  side  views      .              .              .  27t) 

248.  Lateral  incisor  of  upjier  jaw,  front  and  side  views      .              .              .  279 

249.  Cuspidatus  of  upper  jaw,  front  and  side  views            .              .              ,  279 

250.  Upper  first  bicuspid,  front  and  side  views       .              .              .              .  281 

251.  Upper  second  bicuspid,  front  and  side  views               .              .              .  281 

252.  First  molar  of  the  upper  jaw                 .....  282 

253.  Second  molar  of  the  upper  jaw            .              .                             .              .  282 

254.  Third  molar  or  wisdom  tooth  of  the  upper  jaw            ,              .              .  283 

255.  Central  incisor  of  the  lower  jaw,  front  and  side  views             .              .  285 

256.  Lateral  incisor  of  the  lower  jaw,  front  and  side  views             .              .  285 

257.  Cnspidatus  of  the  lower  jaw,  front  and  side  views      .              .              .  285 

258.  First  bicuspid  of  the  lower  jaw,  i'ront  and  side  views      •         .              .  285 

259.  Second  bicusi)id  of  the  lower  jaw,  iront  and  side  views         .              .  285 

260.  First  molar  of  the  lower  jaw                .....  287 

261.  Second  molar  of  the  lower  jaw            .              .              .              .              .  287 

262.  Third  molar  of  the  lower  jaw  right  side           ....  288 
2G3.   Coleman's  forceps  for  tlie  removal  of  upper  first  and  second  molar 

roots              ........  292 

264.  The  above  applied  to  a  molar  root     .....  292 

265.  Forceps  for  separating  the  fangs  of  upper  molar  teeth             .              .  29." 

266.  Stevens'  forceps  for  extracting  the  roots  of  upper  molars        .              .  293 

267.  Baly's  forceps  for  extracting  the  i-oots  of  upper  molars           .              .  293 

268.  Coleman's  forceps  for  extracting  the  roots  of  upper  third  molars       .  294 
209.   Forceps  for  extracting  the  roots  of  lower  molar  teeth  when  attached 

to  the  crowns             .......  295 

270.  George's  elevator,  front  and  side  view             ....  295 

271.  Tomes'  elevator,  with  a  spoon-shaped  bhule  ....  290 

272.  Scissors  with  the  blades  at  an  angle  to  the  handles     .              .               .  298 

273.  Elevator  Avith  the  blaiies  at  an  angle  to  the  handles  .              .               .  299 

274.  Elevator,  the  blade  of  which  can  be  set  at  any  angle              .              .  299 

275.  Thompson's  elevator               ......  299 

276.  Two  forms  of  screw  instruments  for  extracting  roots  of  teetli               .  300 

277.  Teeth  which  would  present  a  considerable  resistance  in  their  removal  3(t4 

278.  A  trephine  for  removing  the  alveolar  process  in  front  of  a  tooth        .  304 

279.  Malformed  upper  third  molar,  to  which  the  ordinary  forceps  could 

not  be  properly  adjusted      ......  304 

280.  Forceps  for  extracting  lower  incisors  and  cuspidati  when  crowck'd     .  305 

281.  Forceps  for  extracting  upper  incisors  and  cuspidati  when  crowded     .  305 


XX  LIST    OF    ILLUSTRATIONS. 

PIO.  PAGE 

282.  Cattlin's  alveolar  forceps  witli  saw-edged  blades         .             .  .  30G 

283.  Coleman's  mouth-oiK-ner  or  gag. — The  instrument  as  applied  .  307 

284.  Steel  probes  of  various  curves  for  detecting  unerupted  teeth  .  308 

285.  Upper  first  molar  tooth  with  a  portion  of  the  external  alveolar  plate 

attached       .  .  .  .  .  .  .  .310 

286.  Upper  third  molar  with  the  tuberosity  of  the  superior  maxilla  attached     310 

287.  Forceps  for  cutting  away  projecting  portions  of  alveolar  pi-ocess,  etc.       311 
[288.  "Wedge  cutter  .  .  .  .  .  .  .312] 

289.  Diagrammatic  representation  of  the  arteries  of  the  right  side  of  the 

neck  ........       317 

290.  Richardson's  cther-spi-ay  apparatus    .....       321 

291.  Complete  apparatus  for  generating  nitrous  oxide  gas  .  .       325 

292.  Gasometer  for  collecting  and  storing  nitrous  oxide  gas  .  .       326 

293.  Simple  form  of  apparatus  for  administering  nitrous  oxide      .  .       326 

294.  Nitrous  oxide  apparatus  ......       327 

295.  Clover's  face-piece  and  two-way  stopcock      ....       328 

296.  Simple  form  of  mouth-prop  or  gag     .  .  .  .  .331 

297.  Mc Adam's  mouth-prop  .  .  .  .  .  .331 

298.  Electro-magnetic  apparatus  for  stimulating  the  heart's  action  .       335 

299.  Diagram  illustrating  Lauder  Brunton's  views  of  the  (-ause  of  arrest  of 

the  heart's  action  under  chloroform  administration  .  .        337 

300.  Coleman's  chloroform  apparatus         .  .  .  .  .341 

301.  Apparatus  represented  in  Fig.  300  with  a  nose  piece  for  maintaining 

antesthesia  Avith  the  mouth  open      .....  341 

302.  Coleman's  apparatus  for  administering  chloroform  through  the  nose  342 

303.  Chair-couch  for  operations  upon  the  mouth  under  chloroform             .  342 
[304.  The  S.  S.  White  pedal  lever  chair  .....  343] 

305.  A  form  of  scaler  for  removing  tartar  ,  ....        358 

306.  Two  forms  of  polishing  brushes  to  be  nsed  with  the  dental  engine     .        359 

307.  Necrosis  of  nearly  the  whole  of  the  i-ight  superior  maxilla  Ibllowing 

ulcerative  stomatitis  ......       364 

308.  Hypertrophy  of  gum  which  disappeared  after  removing  some  loose 

teeth  .  .  .  .  .  .  .  .374 

309.  Case  of  considerable  exostosis  of  the  lower  jaw  .  .  .  378 

310.  Cystic  tumor  of  the  upper  jaw  caused  by  a  diseased  bicuspid  root  .  380 

311.  A  cyst  removed  with  a  bicuspid  of  the  upper  jaw      .  .  .  382 

312.  Small  cyst  in  connection  with  a  bicuspid  root  ....  385 

313.  Instrument  for  making  an  opening  into  the  antrum    .  .  .  388 

314.  Diagrammatic  representation  of  the  fifth  pair  of  cerebral  nerves  .  3D3 


MANUAL 


DENTAL  SURGERY  AND  PATHOLOGY. 


CHAPTER    I. 

TFIE  FIRST  DP:NTITI0N. 

That  the  Teeth  are  important  agents  in  the  animal  economj, 
evidence  is  aftbrded  in  their  early  development ;  for,  at  the 
seventh  week  of  intra-uterine  existence  may  be  seen  the  com- 
mencement of  these  organs,  which  enable  the  possessor  to 
become  independent  of  the  maternal  parent.  In  order  that  this 
independence  should  be  possible  at  an  early  period  of  existence, 
most  animals  are  provided  with  two  sets  of  teeth,  one  temporary 
and  comparatively  rajjidly  developed,  which  appears  generally 
at  or  soon  after  birth,  and  supplies  the  individual  with  the 
means  of  securing  and  comminuting  its  food  during  the  period 
while  the  second  and  more  permanent  organs  are  undergoing 
their  slower  and  more  perfect  development.  [This  is  especially 
true  of  the  higher  mammalians.  According  to  Owen,  replace- 
ment occurs  in  them  but  once.'  The  phenomenon  of  a  third 
dentition  in  man  j-et  requires  verification.  Occasionally,  cases 
of  eruption  of  one  or  more  third  teeth  may  take  place,  but  that 
an  entire  dentition  should  be  rejilaced  a  second  time  seems  to  be 
very  rare  if  not  entirely  unauthenticated.] 

Man,  of  all  animals  the  most  dependent  upon  his  own  species, 
is  not,  as  a  rule,  furnished  with  any  teeth  until  nearer  the  end 
than  the  commencement  of  the  first  year  of  his  existence,  and 

[I  'I  Owen's  Odontography,  or  a  Treatise  on  the  Comparative  Anatomy  of  the 
Teeth,  etc.,"  vol.  i.  p.  307.     Hippolyte  Bailliere,  London,  1840-45.] 
2 


18  MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

the  process  has  seldom  terminated  much  before  manhood  is 
attained.  During  the  period  between  birth  and  the  possession 
of  a  sufficient  number  of  teeth  to  render  tlie  individual  inde- 
pendent of  the  mother,  it  is  sup|)lied  with  a  food  in  form  and 
composition  the  most  suitable  to  its  requirements,  viz.,  a  bland, 
palatable  fluid,  holding  in  solution  all  the  constituents  out  of 
which  its  various  tissues  can  be  nourished  and  developed.  The 
young  animal  merely  drinks  its  food,  which  it  can  readily 
digest  in  its  more  simply  developed  alimentary  canal.  Con- 
temporaneously with  the  development  of  the  teeth,  other  organs 
are  also  becoming  developed,  whose  function  will  be  necessary 
when  the  former  are  so  far  advanced  as  to  enable  the  individual 
to  obtain  its  food  from  other  sources,  and  which,  being  of  a  less 
simple  form  and  character,  will  require  more  complicated  pro- 
cesses to  bring  it  into  a  condition  in  which  it  can  be  assimilated 
and  turned  to  the  same  account. 

If  we  examine  the  mouth  of  an  infant  shortly  after  birth,  we 
shall  see,  more  or  less  distinctly,  the  outlines  of  the  forms  of  the 
temporary  teeth — especially  the  front  ones — situated,  apparently 
a  very  little  distance  beneath  the  surface  of  the  gums  on  the 
external  aspect  of  the  jaws.  As  the  infant  grows  older,  they 
become,  owing  to  the  increased  development  of  the  alveolar 
processes  and  mucous  membrane,  less  and  less  apparent,  until 
the  outline  is  almost  lost.  A  little  ridge,  on  the  summit  of  each 
jaw,  and  closely  resembling  a  cicatrix,  scarcel^^  if  ever  percepti- 
ble at  birth,  becomes  more  apparent  as  the  period  of  dentition 
approaches:  it  is  probably  the  developed  remains  of  the  "primi- 
tive Dental  Groove"  of  Goodsir,  the  dipping  down  of  the  fold 
of  "  epithelium,"  from  which  the  enamel  is  developed.  During 
the  period  prior  to  dentition,  it  will  be  remarked  that  the  mouth 
of  the  infant  is  less  moist  than  is  that  of  the  adult;  Avhilst,  as 
dentition  aiijiroaches,  the  reverse  is  apparent,  the  saliva  gener- 
ally flowing  in  considerable  quantity  from  the  infant's  mouth. 
AVhilst  supplied  with  fluid  food,  the  office  of  the  saliva,  in  lique- 
fying and  lubricating  it  at  the  commencement  of  the  alimentary 
canal,  is  not  called  for;  but,  as  the  time  approaches  for  a  harder, 
drier,  and  more  complicated  food  being  sought  for,  the  salivary 
glands  become  more  perfectly  developed.  Unduly  stimulated, 
no  doubt,  by  the  irritation  of  dentition,  their  secretion  becomes 
abnormal  in  quantity,  and  thus,  draining  the  blood  at  this  region 


THE    FIRST    DENTITION, 


19 


of  certain  of  its  constituents,  reduces,  as  some  have  supposed, 
tlie  tendency  to  inflammatory  action  ;  a  view  supported  by  tlie 
fact,  that,  in  certain  inflammatory  conditions  of  the  guras,  relief 
is  often  secured  by  producing  this  condition  artificially,  by  the 
agency  of  what  are  termed  sialagogues.  [In  which,  at  least, 
the  practitioner  follows  the  apparent  action  of  nature,  for  many 
who  have  cut  the  sensitive  dentine  of  teeth  have  noticed  the 
immediate  augmentation  of  the  flow  of  saliva.  So  constantly 
is  this  witnessed  that  it  may  be  accepted  as  an  indication  of  the 
intensity  of  the  pain  and  irritation  inflicted.] 

As  the  period  of  dentition  approaches,  it  will  be  noticed  that 
the  now  greatly  increased  alveolar  processes  present  on  their 
summits  uneven  elevations,  like  mounds  or  hillocks.  They 
vary  much  in  different  individuals:  if  they  be  watched  from 
day  to  day,  we  notice,  as  they  become  more  distinct,  tliat  they 
become  lighter  in  color,  until  they  so  nearly  resemble  that  of  the 
teeth  themselves,  that  it  is  only  by  the  assistance  of  touch  that 
we  can  positively  determine  that  the  teeth  have  been  erupted  ; 
where  the  mucous  membrane  has  been  much  elevated,  its  subsi- 
dence, after  the  eruption  of  a  tooth,  leaves  the  latter  projecting 
some  distance  above  the  level  of  the  surface,  as  if  the  tooth 
were  erupted  more  rapidly  at  this  than  at  other  periods  in  the 
process. 

Fis.  1. 


The  temporary  teeth  of  the  right  side  ia  the  upper  and  lower  jaws,     n,  central  incisors  ; 
b,  lateral  incisors  ;  c,  cuspidati  ;  d,  first  molars  ;  e,  second  molars. 

The  temporary  teeth  in  man  are  twenty  in  number:  ten  in 
the  upper  and  ten  in  the  lower  jaw,  placed  symmetrically  on 
each  side  of  the  mesial  line,  their  formula  (representing  each 
side  of  the  mouth)  is :    incisors  |,  cuspidati  {,  molars  f. 


20     MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

They  receive  their  names  from  either  their  form  or  their 
office,  thus:  incisors  —  cutters;  cuspidati  —  pointed;  molars — 
grindei*s. 

Tlie  order  and  periods  in  which  the  temporary  teeth  are 
erupted — the  first  dentition,  as  the  process  is  called,  or  more 
popularly,  "  teething" — are  suhject  to  great  variation.  Teeth 
may  he  erupted  at  or  even  prior  to  hirth,  or  they  may  not  appear 
until  the  second  year  has  been  almost  completed  :  extremes 
which  that  master-observer  of  human  nature,  Shakspeare,^  has 
not  overlooked.  The  writer  has  met  with  several  instances  of 
well-formed  teeth  occurring  in  the  mouths  of  children  at  birth, 
and  a  few  cases  where  "  teething"  did  not  commence  till  after 
the  twentieth  month.  Formerly,  it  was  the  practice  to  remove 
the  teeth  erupted  at  or  soon  after  birth,  it  being  almost  imi)ossi- 
ble  for  such  children  to  be  nursed  at  the  breast;  but,  since  the 
introduction  of  india-rubber  nipple-shields,  this  harsh  treatment 
has  been  abandoned.  These  cases  are,  however,  different  from 
those  in  which,  at  or  near  birth,  small  sharp  teeth,  loosely 
attached  to  the  mucous  membrane,  and  having  no  fangs,  are 
discovered  in  the  mouths  of  infants.  These  should  be  at  once 
removed,  as  they  will  prove  only  a  source  of  distress  to  the 
possessor.  Tliey  are  the  exfoliated  calcified  caps  of  dentine  of 
necrosed  temporary  teeth,  and  their  existence  would  lead  us  to 
a  strong  suspicion  that  the  child  is  the  subject  of  inherited 
s^'philis.^ 

In  the  healthy  individual  we  may  look  for  a  lower  central 
incisor  n)aking  its  aiipearance  about  the  commencement  of  the 
eighth  month,  and  being  joined  by  its  fellow  within  a  week  or 
80  afterwards.  After  an  interval  of  two  'to  three  months, 
appears  a  central  incisor  of  the  up[)er  jaw,  followed  soon  after- 

'    York.     Marry,  they  say,  my  uncle  grew  so  fast, 

That  he  could  gnaw  a  crust  at  two  hours  old  ; 
'Twas  full  two  years  ere  I  could  get  a  tooth. 
Grandam,  this  would  have  been  a  biting  jest. 

Richard  III..,  act  ii.,  sc.  iv. 
2  The  writer  liad  tlip  opportunity  of  seeing  the  following  curious  case  in  the 
practice  of  his  friend,  G.  K.  Ord,  of  Streatham.  A  child  had  at  birth  a  sac-like 
projection  of  the  mucous  membrane  about  the  symphysis  of  the  lower  jaw,  in 
which  could  be  felt  the  two  central  incisors  quite  loose ;  as  it  impeded  the  child 
in  sucking,  Mr.  Ord  opened  it,  and  removed  two  imperfectly  developed  but 
living  teeth.     In  tliis  case  there  Mas  no  suspicion  of  syphilis.  — [A..  C] 


THE    FIRST    DENTITION.  21 

wards  by  its  comrade,  and,  within  a  month  to  six  weeks,  by  the 
lateral  incisors  of  the  same  jaw.  Some  authorities,  erroneously 
we  consider,  name  the  lateral  incisors  of  the  lower  jaw  as  next 
in  succession  to  the  central  incisors  of  the  upper  jaw  ;  but  these 
do  not  generally  appear  until  after  the  corresponding  teeth  of 
the  upper  jaw  have  been  erupted  some  two  months,'  bringing 
the  period  to  twelve  months  or  thereabouts;  and  within  another 
period  of  two  months,  and  at  some  little  distance  from  the 
lateral  incisors,  and  postei-ior  in  the  dental  arch,  will  appear  the 
four  first  molars.  A  i)ause  of  four  to  five  months  ensues  before 
the  "cuspidati,"  the  next  in  order,  appear,  which  will  be  when 
the  individual  is  about  eighteen  months  old;  and  they  take 
their  position  in  the  spaces  left  between  the  lateral  incisors  and. 
first  molars,  and  many  authorities  consider  that  in  their  erup- 
tion more  trouble  is  experienced  than  with  any  of  the  other 
teeth  ;  if  so,  it  is  not  attributable  to  their  size  and  form,  as  of 
all  the  teeth  we  should,  judging  from  these,  expect  the  cuspidati 
to  be  the  easiest  to  erupt.^ 

The  cuspidati  occupy  about  two  to  three  months  in  their 
eruption,  and,  after  an  interval  in  the  process  of  three  to  five 
months,  appear  the  second,  molars — the  fifth  and  last  group — 
about  the  beginning  of  the  second  year.  They  take  a  position 
in  the  dental  arch  posterior  to  the  first  molars,  and.  are  all 
usually  erupted  within  a  period  of  three  to  five  months,  when 
the  process  of  the  first  dentition  will  be  completed,^  which   is 

'  Trousseau  and  C.  S.  Tomes  adopt  this  arrangement,  and  West  probably, 
but  there  is  evidentlj^  some  error  in  the  text  of  his  work,  "  Diseases  of  Infancy 
and  Childhood,"  5th  edit.  p.  5.13,  line  9,  et  neq.  Ashburner  adopts  the  other, 
viz.,  that  the  lateral  incisors  of  the  lower  jaw  are  erupted  before  those  of  the 
upper. 

2  West  regards  the  first  molars  as  being  the  teeth  to  cause  generally  the  most 
trouble  ;  Trousseau  and  some  others  the  cuspidati,  and  account  for  it  "from 
their  having  long  roots,"  "their  sockets  being  very  narrow,  and  their  being 
erupted  between  teeth  already  cut,"  "the  distance  they  are  developed  from  the 
surface  ;"  reasons  which  we  consider  in  themselves  insufficient  as  explanations, 
the  condition  of  the  nervous  system  at  the  period  having  probably  more  influ- 
ence in  the  matter  than  any  local  conditions. 

2  The  arrangements  and  dates  which  we  have  given  are  mainly  those  of 
Trousseau,  whose  calculations  are  based  upon  the  observations  of  his  pupil 
Duclos ;  he,  however,  gives  the  period  of  eruption  of  the  first  tooth  at  six 
months  and  a  half,  which  we  con-sider  earlier  than  the  average,  and  we  there- 
fore  prefer  adopting  the  commencement  of  the  eighth  month  as  such  period. 


22     MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

said,  and  we  believe  correctly,  to  commence  earlier,  and  termi- 
nate sooner,  in  girls  than  in  bojs.  Certain  diseases,  especially 
rickets,  are  stated  to  delay  the  period  of  eruption. 

To  assist  the  memory,  the  following  table,  wliich  is  a  fair 
approximation  to  the  truth,  may  be  found  useful : — 

Group  Months 

1.  Lower  central  incisors  .         .         .         .         .7 

duration  of  eruption  1  to  10  clays 
pause  2  to  3  mouths. 

2.  Upper  central  and  lateral  incisors        ...       9 

duration  of  eruption  4  to  6  weeks 
pause  2  months. 

3.  Lower  lateral  incisors 12 

First  molars 14 

duration  of  eruption  1  to  2  mouths 
pause  4  to  5  months. 

4.  Cuspidati 18 

duration  of  eruption  2  to  3  mouths 
pause  3  to  5  months. 

5.  Second  molars 26 

duration  of  eruption  3  to  5  months.' 

The  period  of  the  first  dentition  is  one  watched  with  more  or 
less  anxiety,  as  it  is  well  known  to  be  a  critical  one,  for  good 
or  evil,  in  the  history  of  the  individual.  An  infant,  healthy 
up  to  the  time  of  teething,  may  then  show  symptoms  of  future 
delicacy  or  disease;  it  is  evidently  a  time  of  trial,  as  is,  we  well 
know,  the  period  when  the  young  of  the  feathered  tribe  are 
changing  their  down  for  feathers.  Infants  w^eak  and  delicate 
from  their  birth  often  go  through  the  process  of  dentition  under 
most  comfortable  conditions,  whilst  fine  and  apparently  strong 
ones  may  sufter  severely,  and  are  left  witli  lesions  which  impair 
their  future  well-being. 

['  The  children  of  this  country  (U.  S.)  frequently  erupt  their  teeth  from  one- 
half  to  one- seventh  earlier  than  these  dates.  Whether  this  apparent  precocity 
is  due  to  the  very  general  encouragement  of  children  to  eat  of  adult's  food, 
or  to  the  difference  of  climate,  is  as  yet  undetermined.  The  inconveniences 
attending  suckling,  generally  here  submitted  to  by  tlie  mother,  may  result 
in  earlier  weaning  tlian  where  it  is  to  the  interest  of  the  wet-nurse  to  prolong 
her  season  of  pecuniary  profit.  On  the  other  hand,  the  earlier  maturation 
here  of  many  of  tiie  cereals,  owing  to  the  higher  average  temperature,  may  be 
an  argument  favoring  the  idea  of  earlier  development.  It  is,  however,  unsafe 
to  rely  implicitly  upon  tables  which  are  only  compiled  to  express  averages. 
The  symptoms  showing  a  disturbance  of  the  general  system  in  teething  are,  of 
course,  in  individual  cases  the  most  correct  guides.] 


THE    FIRST    DENTITION.  23 

Under  the  most  ftivorable  circumstances,  the  teeth  may 
appear  one  after  another  at  the  usual  time,  and  in  the  groups 
named,  with  so  little  ap[)arent  disturbance  to  the  individual, 
that  their  presence  may  be  only  accidentally  discovered;  more 
commonly,  however,  the  child,  tor  some  little  time  [)reviou3  to 
the  eruption  of  each  group,  becomes  restless,  has  an  increased 
flow  of  saliva,  and  more  or  less  often  presses  its  knuckles  against 
the  gums.^  The  mouth,  if  examined  at  such  period,  will  ex- 
hibit the  gums  somewhat  swollen,  and  of  a  rather  higher  tem- 
perature than  usual,  and  more  than  normally  injected  with 
blood.  As  the  process  advances,  the  more  elevated  portions  of 
the  gum  become  of  a  paler  color,  until,  as  before  stated,  they 
so  resemble  that  of  the  coming  teeth  that  it  is  almost  impossible 
to  say  when  they  have  actually  penetrated  it.  When  the  group 
of  which  they  are  members  are  all  erupted,  the  symptoms  for 
the  time  usually  disappear.  In  many  cases,  however,  the 
condition  of  matters  is  not  so  favorable;  for  some  time  previous 
to  the  eruption  of  each  tooth  or  group,  the  child  becomes  fret- 
ful and  irritable,  and  the  gums  appear  hot,  swollen,  and  tender; 
the  rubbing,  evidently  grateful  in  the  former  cases,  now  causes 
pain  and  resistance,  and  infants,  from  this  cause,  are  seen  to 
relinquish  the  breast,  suddenly  crying  and  struggling.  If  the 
symptoms  are  more  severe,  they  are  not  confined  to  the  local 
ones;  the  little  sufferer  is  feverish  and  thirsty,  evidenced,  as 

'  To  the  natural  irritation  experienced  in  dentition,  wliich  in  the  lower  ani- 
mals probably  never  exceeds  more  than  a  slight  amount  of  discomfort,  a  useful 
purpose  may  be  assigned.  The  sensation  of  thirst,  arising  from  deficiency  of 
fluid  in  the  blood,  is  referred  to  the  region  of  the  mouth  and  fauces,  and  we  can 
readily  comprehend  the  young  animal  grasping  in  consequence  the  teat  of  the 
mother  by  the  mouth.  The  sense  of  hunger,  arising  from  deficiency  of  solid 
nutritive  material  in  the  blood,  is  less  definite  in  its  location,  and  is  felt  in  re- 
gions which  are  not  accessible  to  applications. 

At  the  period  of  teething,  the  young  animal  is  continually  applying  to  its  mouth 
various  solid  substances,  as  our  mats  and  carpets  often  testify,  and,  no  doubt 
finding  some  of  the  substances  palatable  and  agreeable,  swallows  them.  Soon 
the  sense  of  smell  recalls  to  the  creature  the  recollection  of  that  Avith  which, 
previously  an  agreeable  taste  was  connected.  Sight  also  assists,  and  these  two 
senses  soon  enable  the  individual  to  select  its  own  food,  and  become  wholly 
independent  of  the  maternal  supply. 

[N.  B. — The  above  condition  in  the  lower  animals  is  much  modified  by  the 
practice  of  artificial  rearing  of  the  domestic  animals,  now  so  generally  being  fol- 
lowed in  various  selections  of  breed,  etc.,  producing  conditions  approaching 
more  nearly  the  artificial  life  of  man.] 


24:     MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

West  points  out,  by  its  sucking  greedily  at  the  breast  and 
tben  vomiting  a  portion  from  tlie  more  tban  satisfied  stomach. 
[This  must  not  be  confounded  with  the  mere  regurgitation  of 
food,  the  milk  coming  up  comparatively  pure  and  sweet  imme- 
diately after  feeding,  in  consequence  of  the  child's  movements 
causing  pressure  of  the  abdominal  walls  upon  the  over-distended 
stomach.]  Diarrhoea,  the  result  of  extended  or  reflex  irritation 
to  the  intestinal  mucous  membrane,  is  not  uncommon,  the 
motions  being  often  offensive,  and  having  the  so-called  chop- 
ped-spinach  appearance,  as  when  mercury  has  been  adminis- 
tered, A  troublesome  cough,  likewise  the  result  of  irritation 
conveyed  to  the  respiratory  mucous  tract,  often  sets  in  witli 
the  eruption  of  each  tooth,  and,  like  the  diarrhoea,  ceases  when 
the  tooth  or  group  has  become  erupted.  But  the  symptoms 
most  to  be  dreaded  are  those  which  show  the  nervous  sj-stem 
to  be  influenced;  for,  although  West  has  taught  us,  and  no 
doubt  correctly,  to  regard  convulsions  in  the  infant  as  compara- 
ble to  delirium  in  the  adult,  they  yet  appear,  even  when  arising 
only  from  the  cause  in  question,  to  be  capable  of  leaving  lesions 
more  serious  than  are  generally  seen  to  follow  the  delirium  of 
prostrating  illnesses. 

Thus,  in  cases  where  the  convulsions  have  been  very  severe, 
the  brain  occasionally  appears  to  have  been  permanently  affected 
therel)y,  and  this  wliere  there  may  be  no  reason  to  suspect 
tubercular  or  other  constitutional  taint;  nor  are  such  results 
confined  to  the  brain  alone:  the  most  distant  parts  may  suffer, 
as  seen  in  the  cases  of  talipes  equinus  resulting  from  this  cause. 

During  the  eruption  of  the  temporary  teeth,  cutaneous  aftec- 
tions  are  by  no  means  uncommon,  the  most  frequent  and 
troublesome,  after  the  fugitive  and  unimportant  erythematous 
and  pajiulous  rashes,  being  eczema,  impetigo,  and  herpes. 

Teething  is  a  natural  process,  and  n(^t  a  disease,  yet  it  does 
occasionally  ha|>i)en  that  a  cliild  may  be  said  to  die  directly 
from  it,  and  independently  of  any  of  its  com[»lications,  A  weak 
child  may  be  so  exhausted  by  the  process  as  to  sink  under  it. 
A  marked  case  came  under  the  notice  of  the  writer: — a  male 
infant,  which  had  tiie  misfortune  to  lose  its  niother  at  the  birth, 
and,  with  her,  that  means  of  nourishment  most  adapted  for  a 
weakly  child,  did  fairly  well  up  to  the  usual  period  of  teething, 
when  tooth  after  tooth,  irrespective  of  group,  rapidly  made  its 


THE    FIRST    DENTITION.  25 

appearance;  the  appetite  fell  off,  yet  the  food  taken,  though 
small  in  quantity,  was  fairly  digested;  the  little  sufferer's  rest 
was  hroken,  and  it  gradually  lost  strength  from  day  to  day, 
and  week  to  week,  until  it  finally  sank,  exhausted.  Now,  had 
this  weakly  child  erupted  its  teeth  in  grouiis,  with  the  proper 
periods  of  repose  hetween  each,  instead  of  en  masse,  so  to  speak, 
there  is  fair  reason  to  believe  that  it  might  have  gained  suffi- 
cient strength  in  the  intervals  to  enable  it  to  pass  through  the 
trials  as  they  arrived.  In  this  case  there  was  no  disease,  and 
therefore  there  could  be  no  actual  treatment,  and  this  may  be 
said  of  teething  in  general.  [Sometimes  lancing  freely  seems  to 
restore  the  normal  conditions,  and  delay  teeth  that  are  prema- 
turely erupting.] 

But,  whilst  there  is  no  specific  for  teething,  much  may  often 
be  done  to  allay  symptoms,  care  being  taken,  however,  that  they 
are  not  mistaken  as  arising  from  this  cause,  when  they  have  in 
fact  another  and  a  more  serious  origin.  When  the  process  is 
naturally  conducted,  the  less  nature  is  interfered  with  the  better; 
but  we  may  inculcate  on  those  having  charge  of  infants  the 
importance  of  their  being  especially  guarded,  particularly  dur- 
ing the  erup)tion  of  a  group,  from  things  in  respject  of  which 
there  is  less  necessity  for  care  when  the  process  is  completed. 
Thus,  at  such  periods,  the  following  matters  should  be  especially 
avoided;  weaning,  or  other  important  changes  in  diet,  exposure 
to  changes  of  temperature  by  alteration  in  clothing  or  situation, 
the  chance  of  infection  of  zymotic  diseases,  etc.,  and  vaccina- 
tion. 

If  called  to  children  whose  symptoms  are  confined  to  local 
ones,  we  may,  if  we  find  the  gums  somewhat  swollen  and  con- 
gested, though  not  tender,  afford  some  relief  by  lightly  scarify- 
ing them  with  a  sharp  lancet; — we  lay  much  stress  ori  sharp,  as 
it  then  causes  very  little  pain,  and,  by  cleanly  dividing  the 
superficial  vessels,  affords  greater  relief  through  freer  bleeding  ; — 
but,  should  the  gums  be  very  tender,  as  evidenced  by  the  cry  or 
altered  cry  of  the  infant  when  it  is  commenced,  it  should  at 
once  be  discontinued,  for  an  inflamed  surface  is  mostly  acutely 
sensitive,  and  the  less  cruel  method  of  applying  a  leech  at  the 
angle  of  the  jaw  should  be  adopted.  We  doubt  whether  much 
relief,  or  relief  of  an}-  duration,  is  attained  by  the  operation  of 
scarifying  the  gums;  yet  that  it  does  afford  relief,  and  cause  but 


20     MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

little  pain,  is  evidenced  by  the  fact  that  we  have  occasionally 
been  asked  by  children,  old  enough  to  do  so,  to  perform  it,  from 
their  recollection  of  the  relief  which  they  had  experienced  on 
former  occasions.  [One  of  the  writer's  children,  before  she  was 
nineteen  months  old,  insisted  upon  the  lancing  of  her  gums,  and 
persevered  until  eight  incisions  were  made  over  the  four  erupt- 
ing molars,  when,  with  an  embrace  and  a  kiss  as  recompense  for 
the  relief  afforded,  she  immediately  fell  into  a  tranquil  sleep.] 
In  case,  however,  of  other  conditions  than  the  merely  local  ones 
prevailing,  should  we  find  the  gums  elevated  at  certain  points, 
and,  on   inquiry,  ascertain  that  certain  teeth  of  a  group  have 

Fis:.  2. 


Three  forms  of  lancet  useful  in  dental  surgery  ;  the  blade  in  a  line  with  the  handle  is  that  best 
suited  for  lancing  the  gums. 

been  erupted,  and  should  the  gum,  moreover,  appear  stretched 
over  such  spots  as  correspond  to  other  members  of  such  group, 
we  may  then  with  advantage  freely  divide  the  gum  until  the 
tooth  is  reached,  which  should  be  but  a  short  distance  from  the 
surface.  In  performing  this  simple  operation,  especially  in  the 
front  of  the  month,  care  should  be  taken  to  incise  upon  the 
anterior  rather  than  upon  the  posterior  asi)ect  of  the  gum  ;  as  it 
niight  be  possible,  in  the  latter  case,  for  the  lancet  to  slide  down 
the  posterior  surface  of  the  tooth  and  injure  the  germ  of  its 
permanent  successor.  The  operation,  however,  should  be  quite 
exceptional;  its  general  employment,  as  was  the  case  some  half- 
century  ago,  was  undoubtedly  cruel  and  uncalled  for;  yet  there 
is  a  danger,  in  the  present  day,  of  a  really  valuable  and  simple 
means  of  allaying  serious  symptoms  being  for  fashion's  sake 
discarded. 

[By  many,  with  whom  my  own  experience  has  universally 
agreed,  it  is  still  deemed  best  to  comjiletely  sever  all  the  bands 
of  overlying  tissue,  thus  entirely  freeing  the  underlying  for- 
mative pulp  and  nervous  tissue  from  the  irritation  of  pressure. 
The   bleeding   relieves   even   deep-seated   congestion,   and    the 


THE    FIRST    DENTITION.  27 

cicatrix  that  may  form  over  the  tooth  is  much  more  readily  pene- 
trated than  the  original  tissue.^  There  is  also  less  liability  to 
other  symptoms  of  a  general  and  serious  nature  such  as  are 
enumerated  in  the  next  paragraph.] 

In  respect  of  the  diarrhcea  accompanying  teething,  and  re- 
garded by  some  as  an  effort  of  nature  to  relieve  or  prevent  local 
inflammations,  and  therefore  not  to  be  actively  dealt  with,  the 
greatest  circumspection  on  the  part  of  the  practitioner  is  requi- 
site; processes  natural  in  themselves  at  the  outset  may  yet 
become  habitual,  and  continue  after  the  cause  of  their  existence 
has  disa[»peared  ;  and  diarrhoea,  simply  the  result  of  the  reflex 
action  of  a  cutting  tooth,  may  soon  result  in  symptoms  alarm- 
ing, and  conditions  difficult  of  control.  It  is  not  always  easy, 
in  cases  of  diarrhoea  occurring  at  the  period  of  teething,  to 
diagnose  its  true  cause,  and  therefore  it  will  be  the  more  pru- 
dent, at  all  events,  to  try  and  restrain  it  within  moderate  bounds, 
even  though  our  suspicions  strongly  point  to  a  dental  origin. 
Our  conclusions  upon  the  subject  may,  however,  be  much  assisted 
by  our  learning  whether,  in  case  of  teeth  having  been  previously 
erupted,  such  conditions  then  prevailed,  and  passed  oft'  when 
the  process  was  accomplished.  Our  attention  should  also  be 
directed  to  ascertaining,  whether  other  portions  of  the  mucous 
membrane  are  likewise  aftected,  as  shown  by  catarrhal  S3'mp- 
toms  generally  ;  and  the  condition  of  the  alvine  ejections,  and 
the  circumstance  of  a  group  of  teeth  being,  or  about  to  be 
erupted,  should  also  be  ascertained.  Above  all,  we  must  inquire 
into  the  conditions  under  which  the  child  is  receiving  its  nutri- 
ment: if  from  the  breast,  then  whether  circumstances  have 
occurred  which  could  alter  the  character  of  the  milk,  or  whether 
the  child  be  allowed  the  breast  too  frequently  or  at  irregular 
intervals;  if  by  hand,  then  whether  any  changes  have  been 
made  in  the  character  of  the  food,  or  in  its  consistency.  The 
milk,  if  that  has  been  employed,  may  have  been  obtained  from 
another  source  or  supplied  in  too  large  quantity,  or  not  suffi- 
ciently diluted — both  very  common  errors  in  the  nurture  of 
infants.     A  child  may  often  do  well  by  hand,  on  milk  and  water 

['  See  "Paget's  Surgical  Pathology,"  Lindsay  aud  Blakistou,  Phila.,  1865, 
pp.  88,  158,  159, 194.  For  example,  a  lip  once  split  by  chapping,  will  after  heal- 
ing open  again  upon  the  slightest  stretching.] 


28     MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

(the  best  food  for  ninety-nine  out  of  a  hundred  children  for  the 
first  year)  until  the  period  of  teething,  when  the  digestive  organs 
appear  less  capable  of  digesting  the  casein  of  cow's  milk,  espe- 
cially when  too  little  diluted  with  water.  As  in  the  milk  of 
cows  casein  exists  in  larger  quantity  than  in  that  of  the  human 
species,  a  certain  dilution,  especially  in  the  case  of  delicate  chil- 
dren at  this  period,  is  essential ;  but  there  is  no  douht  also  that 
it  exists  in  the  former  in  a  less  digestible  form  ;  "  the  casein  of 
cow's  milk  coagulates  in  large  clots,  whilst  woman's  milk  pro- 
duces only  small  flocculent  coagula."  Should  the  casein  be  not 
digested,  w^e  usuallj^  at  first  find  symptoms  of  constipation  ;  the 
motions  are  voided  with  diflficulty  and  pain,  and  are  much  of 
the  consistency  and  appearance  of  dry  putty;  the  action  of  the 
liver  appears  almost  suspended,  and  the  napkins  are  scarcely 
soiled.  If  this  condition  of  things  be  allowed  to  continue, 
diarrhoea,  often  culminating  in  so-called  infantile  cholera,  espe- 
cially in  hot  seasons,  maj"  soon  occur;  but  this  is  not  the  diar- 
riioea  of  teething,  though  it  may  be  greatly  incited  and  aggra- 
vated thereby. 

[It  has  been  the  writer's  practice  always  to  examine  personally 
the  condition  of  the  feeding-bottle  and  appliances.  Of  these 
the  simplest  and  most  easily  cleaned  are  the  best — an  ordinary 
smooth,  strong,  wide-mouthed  bottle,  free  from  thin  scales  of 
glass  and  sharp  edges  or  corners,  either  within  or  without,  and  a 
thin,  black,  elastic,  vulcanized  rubber  nipple.  The  former  should 
be  scrupulously  scalded,  and  both  washed  with  soda  and  water 
immediately  after  using,  and  after  thorough  rinsing  be  kept  in 
clean,  cold  water  that  is  unclouded  by  aii}^  residue  of  milk,  until 
the  time  to  feed  arrives,  which  is  probably  shown  by  the  dis- 
quiet of  the  child.  Then,  tasting  and  being  assured  by  critical 
examination  tiiat  the  milk  is  sweet  and  good,  fresh  from  an  ice 
chest  or  cold  s[)ring-house,  it  may,  if  cow's  milk,  be  slightly 
warmed  by  the  addition  of  one-third  part  of  boiling  water. 
To  this  iriixture  (or  less  advantageously  to  the  milk  imme- 
diately upon  its  being  received  from  the  dairyman),  add  of  lime 
water  one  or  two  teaspoonfuls  for  each  pint  of  milk.  Sweeten 
with  a  small  quantity  of  sugar  of  milk,  say  two  teaspoonfuls  to 
the  pint.  As  the  child  advances  in  age  the  amount  of  water 
may  be  decreased  uj)til  about  the  beginning  of  the  period  of 
dentition,  when  the  milk  may  be  used  pure  from  the  cow,  except 


THE    FIRST    DENTITION.  29 

where  feverish  conditions  point  to  the  desirability  of  dilutinir  it 
with  water.  The  rnles  for  proper  nourishment  for  young  infants 
and  animals  have  probably  been  more  the  result  of  empirical 
domination  than  those  for  any  other  age  in  life;  this  is  the 
natural  sequence  of  the  timidity  of  the  young  mother,  the  dicta- 
tion and  ignorant  confidence  of  the  so-called  experienced  nurse, 
together  with  the  utter  helplessness  of  the  little  sufferer  and  the 
impossibility  of  its  making  known  its  wants.  To  form  arbitrary 
and  invariable  rules  with  regard  to  the  time  of  feeding  and 
amount  or  kind  of  nourishment  to  be  given  to  babes,  is  as  unrea- 
sonable as  it  would  be  to  dress  them  in  clothes  made  according 
to  one  pattern  and  of  one  uniform  material.  Disquiet  and  a 
peculiar  rooling  movement  of  the  nose  and  head  are  generally 
the  signs  of  an  infant's  hunger,  and  invite  attention  to  its  need. 
Many  of  man's  morbid  appetites  come  of  eating  and  chewing 
various  articles  to  temporarily  relieve  the  discon)fort  of  hunger. 
There  is  but  little  danger  of  the  young  of  any  animal  being  over- 
fed, so  long  as  the  food  furnished  is  perfectly  healthy  and  free 
from  condiments  and  unnatural  constituents.  Carbonaceous  food, 
such  as  candy,  sugar,  molasses,  cake,  and  sweets,  is  too  often 
resorted  to  as  placebos  until  a  pernicious  appetite  is  formed  by 
the  child,  which  destroys  the  value  of  the  craving  or  desire  for 
aliment  as  a  guide  to  its  administration.  Sydenham  is  credited 
Avith  the  proposition  that  the  more  nearly  a  medicine  approaches 
a  food  the  better,  but  the  modern  developments  of  knowledge  in 
the  direction  of  physiology  and  pathology  seem  to  warrant  the 
broader  assertion  that  probably  in  the  modification  of  the  diet 
is  to  be  found  the  greatest  power  to  control  or  modify  the  entire 
animal  economy,  and  the  mind  is  often  in  such  sympathy  with 
the  body  as  to  be  likewise  affected  by  the  regimen.  The  im- 
portance of  proper  food  is  such  that  no  parent  can  be  said  to 
have  performed  his  or  her  duty,  in  the  cultivation  of  the  highest 
capabilities  of  the  bodies  or  the  minds  of  their  children,  if  the 
strictest  attention  is  not  paid  to  their  diet. 

For  most  infantile  troubles,  as  already  intimated,  proper  air, 
food,  ajid  clothing,  and  thorough  lancing  when  indicated,  are 
aU-sufficient  when  the  child  has  no  marked  inherited  disease. 
The  diarrhoea  of  our  warm  summer  weather  often,  however, 
requires,  where  the  babe  is  artificially  nourished,  some  special 
modification  of  the  milk.     A  good  plan  is  to  boil  flour  in  a  bag 


30  MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

for  four  hours;  then,  removing  the  outside  crust  when  required 
for  use,  tlie  interior  may  be  grated  to  powder  and  added  to  the 
preparation  above  mentioned  to  form  pa[t.] 

Here  our  attention  must  be  directed  to  diet  almost  exclusively  ; 
goat's  milk  maj'  be  substituted  for  cow's,  and  should  this  not 
prove  ettective,  ass's  milk,  which  more  nearly  approaches  the 
human  than  an}' other  available,  will  often  be  digested;^  or, 
where  these  are  not  accessible,  the  valuable  suggestion  of  form- 
ing a  corajtound  analogous  to  human  milk  may  be  adopted.^ 

[Where  so  situated  as  to  be  unable  to  get  or  keep  cow's  milk 
pure  and  sweet,  children  thrive  for  a  time  upon  condensed  milk  ; 
this  in  the  absence  of  goat's  or  ass's  milk  (both  kinds  very  rare 
in  this  country)  has  done  great  service  in  furnishing  a  healthy 

'  Buttermilk  has  been  much  commended  in  some  parts  of  the  Continent. 

*  To  a  friend  and  former  teacher — Dr.  Frankland,  of  the  Department  of  Sci- 
ence and  Art, — we  are  indebted  for  the  following  plan,  slightly  altered  at  our 
suggestion  with  liis  concurrence,  for  preparing  a  food  for  infants,  closely  resem- 
bling in  its  composition  human  milk. 

Take  the  cream  furnished  by  a  pint  of  milk  and  add  it  to  |  pint  of  new  milk. 
Into  the  skimmed  milk  from  which  the  cream  is  taken,  put  a  piece  of  rennet 
about  one  inch  square,  and  set  the  vessel  containing  it  in  warm  water,  until  the 
milk  is  fully  curdled,  which  should  occupy  about  5  to  15  minutes.  The  rennet, 
being  removed,  washed,  and  then  kept  in  salt  and  water,  will  be  serviceable 
for  a  month.  Next  break  up  the  curd,  and  carefullj'  strain  it  from  the  whey, 
which  latter  should  be  heated  to  the  boiling  point,  and  then  again  strained  from 
the  casein  formed  during  the  boiling  "feelings."  Add  to  the  hot  wliey  110 
grains  of  milk-sugar,  and  when  dissolved  mix  the  whole  with  the  f  pint  of  new 
milk  and  added  cream.  The  artificial  milk  thus  prepared  should  be  used  within 
twelve  hours  of  its  preparation,  and  all  vessels  employed  should  be  scrupulously 
clean. 

Analyses  of  milk,  from  "  Frankland's  Experimental  Researches:" 


Woman. 

Ass. 

Cow. 

Artificial. 

Casein    . 

.     2.7 

1.7 

4.2 

2.8 

Butter    . 

.     3.0 

1.3 

3.8 

3.8 

Milk-sugar     . 

.     5.0 

4.5 

3.8 

5.0 

Salts      . 

.       .2 

.5 

.7 

.7 

It  is  not  impossible  also,  that  a  portion  of  the  milk  having  been  acted  on  with 
pepsine,  the  casein  of  the  fresh  milk  added  may  undergo  some  beneficial  change  : 
at  all  events,  the  food  has  in  most  cases  appeared  to  answer  quite  as  well  as 
Iiuman  milk.  Tlie  trouble,  however,  of  preparing  it  is  by  no  means  inconsid- 
erable, and  would  lead  most  to  seek  the  more  simple  yet  morally  doubtful 
expedient  of  a  wet  nurse. 

In  large  institutions,  such  as  foundling  hospitals,  etc.,  this  process  might  no 
doubt  be  adopted,  and  willi  great  advantage. 


THE    FIRST    DENTITION.  31 

and  nonrislnng  temporary  substitute.  But  persons  who  desire 
to  raise  healthy  children,  and  who  arc  compelled  to  make  use  of 
artificial  food,  must  be  prepared  to  seek  such  localities  as  aflTord 
pure  fresh  cow's  milk.  Who  would  expect  to  become  a  success- 
ful grazier  and  raiser  of  cattle  where  the  food  had  to  be  imported? 
Yet  parents  give  less  thought  on  this  matter  with  reference  to 
their  children  than  to  their  stock. 

In  this  country  n)Ost  physicians  have,  from  English  authori- 
ties and  training,  been  more  or  less  forgetful  of  our  extremes  of 
temperature  and  the  modifications  of  dress  demanded  by  them. 
In  winter  the  child  should  live  in  roomsonly  moderately  Avarmed 
(during  the  day)  by  direct  radiation  of  heat  from  a  stove,  or  bet- 
ter by  an  open  fire,  and  be  clad  in  heavy  woollen  material.  The 
sleeping  a[iartments  should  ofl:er  free  admission  of  the  outside 
air  through  large  open  windows,  and  during  the  arctic  waves  fur 
covering  at  night  is  advisable.  The  summer,  however,  often 
requires  the  tropical  dress  of  simple,  flowing,  loose  night  shirts 
of  cotton  stuff  for  even  a  week  or  more  at  a  time  during  the 
prevalence  of  our  hot  waves.  Many  weak  children  have  been 
and  will  continue  to  be  sacrificed — the  unreasoning  prejudice 
of  tlieir  sliould-be  protectors  tormenting  them  to  a  sure  but 
painful  death  during  the  heated  terms  by  flannel  clothing,  or 
inviting  the  horrors  of  croup  in  winter  by  the  sudden  changes 
from  a  tropical  atmosphere  in  the  nursery  to  a  polar  one  with- 
out.] 

In  our  treatment  of  these  cases,  it  will  make  little  difterence 
whether  the  cause  be  teething  or  otherwise;  though,  as  before 
stated,  we  shall  of  course  treat  it,  the  diarrhoea,  in  the  former 
less  actively  ;  next  to  a  correction  of  any  errors  which  w'e  may 
have  discovered,  as  regards  diet  or  exposure  to  cold,  a  common 
factor  in  the  diarrhoea  of  infants,  we  may  with  much  advantage 
administer,  for  three  or  four  successive  days,  a  small  teaspoon- 
ful  of  an  emulsion,  composed  of  equal  parts  of  castor-oil  and 
gum-syrup,  which  may  in  some  cases  be  repeated  more  than 
once  in  the  day,  but  should  be  discontinued  on  the  cessation  or 
moderation  of  the  diarrhoea;  in  severe  cases,  a  small  quantity, 
one  to  three  drops  at  most,  of  vinum  opii  may  be  added,  and 
this  opiated  form  should  be  especially  employed  in  cases  of 
relapse. 

[While,  as  a  rule,  opium  is  a  most  pernicious  drug  for  infants, 


32     MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOaY. 

it  may  be  occasionally  of  use  in  extreme  cases  of  diarrhoea, 
under  the  familiar  form  of  camphorated  tincture  of  opium,  of 
which  ten  to  thirty  drops  may  be  administered  after  the  prima 
via  has  been  cleared  of  its  contents  by  a  purgative  dose,  say  one 
to  two  teas[)0()nfuls,  of  aromatic  syrup  of  rhubarb. 

AVithout  attempting  to  pass  into  a  discussion  of  the  physi- 
ological action,  it  may  here  be  stated  that  some  of  the  obstinate 
cases  of  this  com[»laint  in  both  adults  and  children  have  been 
cured  apparently  b}-  a  teaspoonful  or  tublespoonful  of  pure  cider 
vinegar,  the  former  amount,  diluted  with  water,  for  children.] 

When  the  cliild  is  found  to  be  much  exhausted  and  emaciated, 
great  benefit  often  ensues  from  adding  to  its  food  a  little  brandy, 
"lij  or  iT\^iij  at  each  of  its  meals,  but  not  in  the  whole  exceed- 
ing 8  to  10  drops  in  the  day.  If  there  be  much  vomiting,  the 
same  quanity  of  sal  volatile  may  be  substituted.  The  food  must 
be  greatly  diminished  in  such  cases,  and  perhaps  only  a  tea- 
spoonful  should  be  given  at  a  time,  but  at  more  frequent  inter- 
vals. Great  benefit  is  also  often  experienced  from  the  application 
of  a  large  but  light  linseed-meal  poultice,  apjilied  warm  over 
the  abdomen,  and  covered  over  with  oil  silk,  a  very  small  pro- 
portion of  mustard  only  being  added,  the  surface  being  pre- 
viously slightly  oiled.  Enemata  of  starch  and  laudanun),  about 
"ij  to  "iv  of  the  latter  according  as  they  are  retained,  may  at 
times  be  usefully  employed. 

[This  raw  starch  injection,  with  from  a  half  drop  to  three  drops 
of  liquid  extract  of  opium,  cannot  be  too  highly  recommended 
in  cases  of  dysentery,  where  the  irritated  surface  of  the  rectum 
causes  intense  pain  and  keeps  up  the  disease  at  a  point  so  remote 
from  the  mouth  that  drugs  administered  by  that  orifice  cannot 
reach  their  destination  without  undergoing  change  and  causing 
deleterious  action,  both  constitutionally  and  upon  surfaces  trav- 
ersed in  their  course.] 

When  called  to  an  infant  in  whom  the  symptoms,  however 
slight,  indicate  that  the  nervous  system  is  affected,  we  must 
never  omit  a  careful  inspection  of  the  mouth;  and,  should  there 
be  the  smallest  evidence  for  believing  that  the  symptoms  may 
depend  upon  the  cause  now  before  us,  the  gum-lancet  should  be 
freely  used;  for  little  harm  can  be  done  by  incising,  though 
unnecessarily,  a  healthy  gum,  compared  with  the  mischief  which 
may  result  from  overlooking  this  cause  of  infantile  convulsions. 


THE    FIRST    DENTITION.  33 

« 

The  symptoms  may  be  slight,  such  as  mere  restlessness,  light 
and  uneasy  sleep,  with  the  thumbs  slightly  contracted  on  the 
palms;  or  there  may  be  more  restlessness  accompanied  by  mus- 
cular twitchings,  the  child  sleeping  with  the  eyelids  but  partially 
closed,  moaning  in  its  sleej»,  and  waking  Avith  a  start,  and  cry- 
ing violently  ;  or  the  symptoms  may  be  the  still  more  severe 
ones  of  active  convulsive  movements,  succeeded  after  a  time  by 
complete  unconsciousness.  Should  the  movements  be  unilateral, 
they  would  of  course  most  probably  point  to  another  cause  than 
dental  irritation.  Even  in  the  severest  cases,  the  simple  opera- 
tion of  lancing  the  gums  has,  under  our  hands,  often  allayed  in 
a  marvellously  short  time  the  symptoms  which  have  continued 
more  or  less  for  twenty- four  and  even  thirtj'-six  hours.  But  it 
would  never  be  right  to  depend  upon  this  alone:  tlie  warm  bath, 
to  which  a  handful  of  mustard  is  a  valuable  adjunct,  should  be 
likewise  employed.  To  the  head  if  hot,  cold  should  be  applied, 
whilst  the  feet  on  removal  from  the  bath  should  be  wrapped  in 
hot  flannel.  Should  the  face  be  flushed,  the  pulse  full  and  in- 
compressible, and  the  fontanelles  prominent,  a  few  leeches 
applied  at  the  occiput  and  removed  directly  an  eifect  is  produced, 
will  often  prove  of  great  service:  when  these  cannot  be  obtained, 
an  ounce  or  two  of  blood  according  to  age  may  be  taken  from  • 
the  external  or  anterior  jugular  veins,  and,  when  required,  an 
aperient  must  never  be  omitted.  But  it  is  most  necessary,  in 
treatino;  cases  of  infantile  convulsions  from  teethino;,  not  to 
mistake  for  these  symptoms  somewhat  similar  ones  arising  from 
a  wholly  difterent  cause,  viz.,  the  convulsions  of  aneemia ;  as 
the  above-mentioned  treatment  would  most  probably  be  attended 
with  a  fatal  result.  They  arise  from  the  same  cause  as  do  the 
convulsions  witnessed  in  those  who  have  suffered  from  severe 
liemorrhage  in  parturition,  and  we  well  know  what  would  be 
the  likely  result  of  a  depleting  course  in  such  condition.  The 
following  symptoms — a  pale  though  occasionally  flushing  face, 
a  dry  skin  with  hair  of  head  somewhat  erect,  conspicuous  veins 
and  sunken  orbits  but  prominent  eyeballs,  fontanelles  depressed, 
and  pulse  rapid  and  almost  imperceptible,  and  quick  respiration, 
with  occasionally  a  loud,  shrill,  and  distressing  cry,  often  the 
precursor  of  a  fatal  termination, — call  for  stimulants,  warmth, 
and  nourishment,  rather  than  depletion  or  depressants,  to  arrest 
the  convulsions,  of  which  the  cause  is  not  in  any  such  instance 
3 


3-i  MANUAL    OF    DENTAL    SURGERY^   AND    PATHOLOGY. 

the  tectli,  but  is  probably  an  exhaustive  diarrlioea,  or  imperfect 
nutrition. 

[The  thorough  use  of  the  lancet  has,  accordincr  to  \ny  own 
experience,  been  an  almost  invariable  relief  and  ever  valuable 
remedy  in  reducing  the  nervous  symptoms  of  teething  children, 
that  add  so  seriously  and  often  fatally  to  the  complications  of 
the  conditions  of  many  of  the  diseases  of  that  age.  It  is  a 
sheet  anchor  of  hope  in  moderately  healthy  constitutions,  and 
it  is  urged  upon  the  profession  as  an  instrument  whose  strokes, 
if  properly  made,  equal  the  reputed  power  of  the  passes  of  the 
magician's  wand  in  fairyland. 

The  difficulties  that  obstruct  its  use  are  overcome  without 
much  trouble  by  those  who  are  determined  to  succeed,  and  are 
really  less  than  those  attending  the  forcing  of  a  medicine  down 
the  little  patient's  throat.  Let  the  child  be  held  firmly  and 
immovably  from  the  waist  up  by  a  seated  attendant,  who  holds 
the  infant  in  his  lap,  facing  the  operator  and  the  light,  with 
its  back  against  the  assistant's  breast,  and  the  right  arm  of  the 
latter  over  the  child's  arms,  grasping  them  above  the  elbows, 
while  the  left  hand  over  the  forehead  and  eyes  holds  the  child's 
occiput  under  the  attendant's  chin. 

The  surgeon,  with  a  sharp  curved  bistoury,  guarded  by  a  strip 
of  cloth  wound  around  the  blade,  allowing  only  an  eighth  to  a 
quarter  of  an  inch  of  the  latter  to  be  exposed,  will  make  a  sin- 
gle cut  for  incisor  teeth  in  the  line  of  the  arch,  and  two  cuts, 
forming  the  ISt.  Andrew's  cross,  for  the  other  teeth — in  these 
cases  the  cuts  crossing  the  tooth  diagonally,  "^i'o  do  this,  the 
lancet  should  be  inserted  perpendicularly  through  the  gum, 
until  the  distal  corner  of  the  tooth  is  distinctly  felt,  and  then, 
taking  care  to  hold  it  down  u[)on  the  tooth,  draw  it  forward 
from  the  disto-lingual  or  palatal  to  the  mesio-buccal  or  labial 
angle,  and  from  the  disto-buccal  to  the  mesio-palatal  or  lingual 
ant'le,  com[)letely  severing  all  the  tissues  above  the  teeth. 

Another  and  simple  method  of  holding  the  child,  is  to  seat 
both  the  operator  and  the  attendant  face  to  face.  Lay  the  child 
u}ion  the  hitter's  lap  upon  its  back,  with  its  head  firndy  grasped 
between  the  knees  of  the  operator,  the  wrists  of  the  child  being 
held  by  the  hands  of  the  attendant. 

Without  nerve,  firm  conviction,  and  confidence  in  the  im- 
mense value  of  the  lalicing,  sufficient  to  im[)ress  those  attend- 


TUB    FIRST    DENTITION.  35 

ins;,  and  enable  the  surgeon  to  operate  deliberately,  the  results 
have  so  often  been  vexatious  as  to  have  caused  many  to  con- 
demn the  operation,  when  in  reality  the  failure  was  due  to  their 
own  inefficienc}',] 

Witii  regard  to  the  cutaneous  eruptions  often  seen  during  the 
period  of  teething,  which  anxious  parents  so  urgently  solicit 
the  practitioner  to  cure,  a  palliative  treatment  only  is  the  best 
course  to  pursue,  as  active  interference  is  often  attended  by 
severe  and  |)ermanent  injury  to  other  organs,  especially  the  re- 
spiratoiy.  The  removal  of  the  crusts,  when  large,  by  poultice, 
and  scrupulous  attention  to  cleanliness,  with  perhaps  the  em- 
ployment of  some  mild  astringent  and  cooling  lotion,  form  the 
best  treatment. 

[Starch  mixed  with  cold  water  to  a  creamy  consistency  as  for 
eneraata,  but  without  the  opium,  unless  there  is  great  pain,  Avill 
prove  a  marvellous  remedy  to  apply  to  these  surfaces  of  irrita- 
tion. When  on  the  head,  anointing  w'ith  castor  oil,  and  w^ash- 
ing  with  dilute  solution  of  borate  of  sodium  in  water,  is  a  very 
safe  and  cleanly  treatment.] 

A  disease  has  been  described  under  the  appeUation,  "  odontitis 
infantum,"  in  which  the  gum  over  an  erupting  temporary  tooth 
becomes  swollen,  congested,  and  finally  ulcerated,  when  the 
tooth  has  penetrated  it.  The  examples  we  have  met  with,?,  e., 
if  they  be  thedisease  in  question,  were  certainly,  in  our  opinion, 
no  other  than  cases  of  ulcerative  stomatitis,  moditied  to  some 
extent  hy  the  condition  of  the  parts  during  the  [)rocess  of  denti- 
tion, which  readily  yielded  to  the  specific  for  that  disease,  viz. 
chlorate  of  potash. 

[Sage  tea  and  hone}'  are  very  highly  recommended  also  in 
these  cases,  but  for  cliildren  or  adults  a  simple  touching  of  the 
ulcers  wnth  a  crystal  of  alum,  the  mucous  membrane  surround- 
ing the  parts  immediately  affected  having  been  previously  dried, 
will  generally  produce  the  most  speedy  and  effective  cure.*  In 
stubborn  cases,  Avhere  the  white  ulcerated  surfaces  indicate  the 
presence  of  the  oidium  albicans  (a  parasitic  vegetable  growth 
giving  the  appearance  of  a  dead  and  soaked  piece  of  skin,  or  curd, 
or  layer  of  starch  covering  the  bottom  of  the  ulcer),  a  saturated 

['  Nitrate  of  silver  has  been  recommended  by  Dr.  J.  Win.  White,  "  Holmes's 
System  of  Surgery,"  vol.  ii.  p.  517.     1881.] 


36     MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

tincture  of  iodine  is  invaluable,  and  ma}'  be  applied  bj^  dipping 
tbe  end  of  a  piece  of  wood,  like  a  match  stick,  in  the  solution, 
and  then  applying  to  the  ulcer,  previously  dried  to  prevent 
spreading  of  the  medicament  to  the  surrounding  surface.] 

In  very  delicate  children,  especially  those  who  may  have  suf- 
fered from  hooping-cough,  measles,  etc.,  the  mucous  membrane 
covering  an  erupting  tooth  may  completely  slough ;  for  this  we 
l)ave  found  no  remedy  so  efficient  as  strong  carbolic  acid. 
Another  condition  that  may  be  witnessed  at  this  period  is  the 
formation  of  a  small  sac  containing  serous  fluid  above  the 
summit  of  a  coming  tooth,  which  is  doubtless,  as  suggested 
b}'  J.  Tomes,  an  abnormal  secretion  of  serum  into  the  space 
between  the  enamel  of  the  tooth  and  the  remains  of  the  enamel 
organ. 

In  descrii)ing  some  of  the  untoward  conditions  which  occur 
during  teething,  and  how  they  ma}'  best  be  met,  the  limits  and 
objects  of  this  work  enable  us  only  to  give  but  a  brief  and  con- 
sequently imperfect  outline,  and  the  student  desirous  of  more 
information  will  do  well  to  consult  the  writings  of  West, 
Trousseau,  and  Dickinson,  also  an  excellent  article  in  the 
"Journal  de  Therapeutique"  for  July  25, 1877,  on  the  Diarrhoea 
of  Infants,  by  M.  Blache,  translated  in  the  'Lancet'  of  Se[)tem- 
ber  15,  1877,  from  which  works  we  have  occasionally  quoted 
verbatim. 

[In  our  extreme  warm  weather  I  cannot  too  highly  recom- 
mend the  laying  of  the  child  in  grass  or  open  network  ham- 
mocks, instead  of  the  arms  of  the  nurse  or  upon  the  bed,  to  admit 
of  the  freest  circulation  of  air  about  it,  together  with  frequent 
ablutions  in  water  of  a  temperature  of  85^  to  90-'  Fah.,  to  keep 
down  the  accumulation  of  caloric  and  the  subsequent  danger  of 
heat  fever,  or,  as  it  is  commonly  called,  sunstroke  or  insolation. 
"VVrajiping  the  child  in  a  sheet  and  then  sprinkling  it  with  water 
of  the  above  temperature  Avill  ra[>idly  cool  and  reduce  feverish 
conditions  where  there  are  dryness  of  the  skin  and  lieat  exhaus- 
tion. A  little  brandy  diluted  with  water  may  be  administered 
internally  in  antemia.  In  all  febrile  conditions,  to  sip  a  tea- 
spoonful  of  cool  water,  say  50  to  60°  Fah.  every  quarter  or 
half  liour,  is  most  grateful,  and,  by  keeping  the  mucous  surfaces 
moist  and  replacing  the  loss  of  water  by  evaporation  from  the 
body,  it  will  do  more  to  relieve  suftering,  reduce  the  temperature. 


THE    FIRST    DENTITION.  37 

and  effect  a  cure  than  any  drug  ever  known.  With  young  babes 
cotton  bird-eye  diaper  is  always  preferable  to  linen,  it  being  less 
likely  to  chill,  and  it  is  equally  useful  as  an  absorbent,  while  only 
about  one-fourth  the  price.  The  diapers  should  always  be 
changed  the  moment  they  are  soiled,  then  waslied  and  dried  in 
the  sun  upou  the  grass,  or  hung  out  to  be  aired  until  they  have 
the  freshness  of  smell  that  is  characteristic  of  clean  washed 
material.  Under  all  circumstances  the  abominable  contriv^ances 
of  water-proof  stutfs  to  protect  the  child's  dress  while  feeding, 
and  the  nurse's  lap,  should  be  regarded  as  the  enemy  of  health, 
inasmuch  as  they  retain  the  heat  and  the  imperceptible  perspi- 
ration and  poisonous  effluvia  arising  from  the  body.^J 

['  See  p.  520  to  52G,  Prin.  of  Human  Phj'siology,  by  Wm.  B.  Carpenter,  with 
notes  and  additions  by  Prof.  Francis  G.  Smith,  M.D.  Phihxdelphia,  Henry 
C.  Lea,  1876.] 


38     MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


CHAPTER  II. 

IRREGUI.ARITIES  IX  THE  TEMPORARY  TEETH.  DISEASES  OF 
THE  TEMPORARY  TEETH.  THE  SECOND  DENTITION. 

The  temporary  teeth  have  but  few  abnormal  conditions,  and 
]:>robal)ly  no  diseases  peculiar  to  themselves,  which  are  not  also 
common  to  them  and  the  permanent  teeth  ;  so  that,  whilst  we 
now  point  out  some  of  the  former,  we  shall  reserve  a  description 
of  the  latter  till  we  treat  of  the  diseases  of  the  permanent  teeth. 

In  the  temporary,  as  in  the  permanent  series,  we  may  meet 
with  irregularities  in  size,  form,  number,  and  position.  In 
regard  to  abnormality  in  size,  the  temporary  teeth  differ  less 
than  the  permanent,  but  occasionally  cuspidati,  and  second 
molars,  are  met  with  so  developed  that  they  might  readily  be 
mistaken  for  those  of  the  second  series.  As  it  is  important, 
especially  in  the  treatment  of  irregularities  in  position,  that 
such  an  error  should  be  avoided,  we  may  point  out  that,  inde- 
pendently of  size,  the  teeih  of  the  first  series  may  be  generally 
recognized  by  their  more  delicate  and  translucent  color,  by  the 
enamel  at  their  necks  terminating  in  an  extended  and  abrupt 
manner  (see  Fig.  1,  p.  19),  and,  at  a  time  when  they  could  be  so 
mistaken,  by  their  masticating  surfaces  exhibiting  more  or  less 
evidences  of  wear:  in  tiie  case  of  the  cuspidati,  they  would 
l»robably  be  sliglitly  loose  to  the  touch  at  a  time  when  they 
could  be  mistaken  for  their  successors,  and  in  that  of  the  second 
temporory  molars  their  position  in  the  dental  series  ought  gene- 
rally to  determine  their  true  class. 

In  fornj,  likewise,  the  temporaiy  teeth  are  more  constant 
than  are  the  peru)anent  ones.  With  regard  to  the  number  of 
their  roots  they  do  not  often  vary,  but  observation  on  this  point 
cannot  be  so  certainly  determined,  as  in  the  natural  course  of 
events  they  are  lost  by  absorption,  at  the  period  of  eruption  of 
the  [lermanent  teeth.  We  have  in  our  possession  four  upper 
cus[»idati,  each  bifurcated  at  the  radical  extremity,  and  a  lower 


IRREGULARITIES    IN    TEMPORARY    TEETH. 


39 


molar  with  three  and  aii  iiitpei'  molar  with  four  fajigs.  A  more 
common  departure  is  where  two  teeth  are  united  (geminated) 
together;  the  union  may  occur  in  the  cementum  only,  or  in  the 


Fi-  3. 


Fis?.  4. 


Upper  second  terapov:uy  molar  with  four  fangs. 


Lower  second  temporary  molar  witli   three 
fangs. 


Fit 


dentine  and  enamel.  In  the  latter  case  a  pulp  cavity  may  be 
common  to  both :  union  of  teeth  by  cementum  only  may  take 
place  after  the  teeth  are  developed  as  a  pathological  process. 

In  number  also,  the  temporary  series  are  more  constant  than 
the  permanent.  Absence  from  the  series  is  rare,  although  the 
writer  has  under  observation  a  family  in  which 
one  member  is  deficient  in  the  four  laterals, 
another  in  all  the  incisors  excepting  the  upper 
centrals,  and  a  third  in  W'hom  again  the  lateral 
incisors  are  absent.  In  these  three  cases,  all 
females,  it  could  be  almost  certainly  prognosti- 
cated, from  the  want  of  development  of  the  jaw 
at  birth,  tliat  such  teeth  would  be  ahsent.  In 
this  family  there  is  the  history  of  the  mater- 
nal grandmother  and  a  great-uncle  having  had 
a  deficiency  in  the  second  series.^  [A  case 
similar  to  Fig.  5  occurred  in  the  mouth  of  one  of  the  writer's 
children,  involving  only  the  right  lower  cus|)id  and  lateral 
incisor.] 

Excess  in  number  is,  though  rare,  probably  more  common; 
the  writer  lias  met  with  eight  or  nine  cases  of  an  additional 
lateral  incisor  of  the  upper  jaw,  and  almost  ahvays  well  formed, 
like  teeth  of  the  same  class. 

As  the  temporary  teeth  are  erupted  in  the  line  of  the  position 


Gemination  of  a  tem- 
porary lateral  incisor 
and  cuspidatus  of  the 
lower  jaw,  left  side. 


'  The  writer  has  recently  met  uith  a  case  of  a  little  girl,  in  ■whom  was  want- 
ing one  of  the  temporary  incisors  of  the  lower  jaw,  but  who  now  has  not  only 
the  full  number  of  permanent  teeth,  but  also  a  well-formed  supernumerary 
lower  lateral  incisor. 


40 


MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY, 


of  their  development,  whicli  is  not  so  in  the  case  of  the  perma- 
nent teetli,  they  are,  as  we  should  naturally  expect,  much  less 


Fii^.  6. 


Upper  jaw  of  a  child  in  whicli  the  lateral 
incisors  are  absent. 


Fiff.  7. 


Lower  jaw  of  a  child  in  which  all  the 
incisors  are  absent. 


liable  to  deviation  from  the  normal  arrangement.  Irregularities 
in  position  of  the  temporary  teeth  are  comparatively  rare,  the 
most  common  being  a  slight  overlapping  of  the  upper  central 


Fia;.  8. 


Upper  jaw  containing  a  supernumerary  lateral  on  the  right  side. 

incisors  at  their  mesial  extremities;  occasionally  an  edge  to 
edge  bite,  that  is,  when  the  cutting  extremities  of  the  front 
teeth  of  each  jaw  meet  each  other,  instead  of  the  upper  slightly 
overlapping  the  lower  teeth,  as  is  natural ;  and  more  rarely  this 
is  extended  to  what  is  termed  underhung,  i.  e.^  when  the  lower 
teeth  overlap  the  upper  when  the  mouth  is  closed. 

We  have  noticed  this  latter  taking  place  some  years  after  the 
teeth  have  been  erupted,  their  original  position  having  been 
normal.     Tumors,  by  their  pressure,  will  of  course  also  produce 

[Fig.  9. 


Protrusion  of  tlio  Hupnrior  inei.sors,  a  frcr|uont  result  of  thumb  or  finger  sucking.     (From  the 

Dental  Cosmos.)] 

this  class  of  irregularity.     Thumb-sucking,  likewise,  may  occa- 
sion a  deformity.     We   have  a  case  now   under   observation 


DISEASES    OF    TEMPORARY    TEETH 


41 


where  the  teeth  and  alveolar  process  of  the  right  side  of  the 
upper  jaw  are  considerably  pressed  outwards  hy  this  habit 
always  practised  on  that  side.  [It  is  not  uncommon  for  this 
habit,  unless  cured,  to  be  the  cause  of  a  deformity  in  the  perma- 
nent teeth,  producing  a  disfigurement  giving  an  almost  idiotic 
expression  by  the  protrusion  of  the  upper  incisors  fiir  beyond 
the  lower.     (See  Fig.  9.)] 

With  regard  to  treatment,  we  have  never  seen  occasion  to 
interfere  in  the  case  of  supernumerary  temporary  teeth,  which 
are  sometimes  followed,  and  sometimes  not,  by  permanent  suc- 


Fig.  10. 


[Fig.  11. 


Chin  retractor  as  applied. 


Another  form  of  chin  retractor  which  by 
the  lower  bandage  draws  the  chin  directly 
backwards,  and  by  the  buckles  the  tension 
may  be  altered  at  pleasure.  Both  bandages 
may  be  made  of  elastic  webbing,  and  pads 
may  be  put  under  the  buckles.] 


cessors.  In  the  cases,  however,  where  there  is  an  increasing 
tendency  to  become  underhung,  due  doubtless  to  some  excess  of 
development  in  the  lower  jaw,  or  imperfect  development  in  its 
ascending  ramus,  an  applinnce  for  drawing  back  the  chin,  by 
means  of  an  elastic  band  attached  to  a  cap  for  the  head,  may 
quite  prevent,  at  an  early  age,  the  occurrence  of  this  unsightly 
irregularity. 

The  temporary  teeth  cannot  be  said  to  be  liable  to  any  diseases 
special   to  themselves  which   are  not  common  to  both  series. 


42     MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

Caries,  the  most  common  of  all,  appears  to  arise  from  the  same 
causes,  and  run  much  the  same  course;  still,  there  are  slight 
difterences  which  may  be  briefly  noticed.  It  often  appears  in  a 
very  superficial  form,  attacking  all  the  front  teeth  at  once,  and 
giving  them  an  appearance  of  having  been  eaten  away  by  an 
acid  solvent.  In  its  more  ordinary  forni,  its  progress  appears 
somewhat  mote  rapid,  and  attended  by  necrosis  at  an  earlier 
period,  which  may  perhaps  arise  from  the  temporary  teeth  con- 
taining a  larger  proportion  of  organic  constituents  than  do  the 
permanent  ones.^  The  result  of  this  loss  of  vitality  is  usually 
alveolar  abscess,  or  gum-boil,  appearing  generally  on  the  labial 
aspect  of  the  gum:  the  bone  lost  by  the  process  at  this  portion 
of  the  jaw  leads  to  the  necrosed  fangs  of  these  teeth  becoming 
exposed  at  such  points  during  the  eruption  of  the  permanent 
teeth,  where  they  are  not  unfrequently  mistaken  tor  small  ex- 
foliations of  bone;  or,  if  overlooked,  they  may  penetrate  into 
the  adjacent  cheek,  setting  up  considerable  ulceration  and  swell- 
ing, followed  often  by  cicatrices  which  bind  the  cheek  at  those 
points  to  the  jaw.  When  this  occurs,  they  should  of  course  be 
removed,  and  the  operation  may  be  eftected  in  a  very  easj' 
manner.  "Where  the  fang  is  not  exposed  in  its  whole  length, 
i.  e.,  where  on]y  a  portion  of  its  apex  penetrates  the  gum,  the 
latter — the  isthmus-like  portion — should  be  divided  by  the  lan- 
cet, and  then,  a  pointed  elevator  being  placed  a  little  aijove  or 
below  (as  the  ease  may  be)  and  behind  the  apex  of  the  fang, 
a  downward  or   upward   and   slightly  inward   movement  will 

■  The  temporary  teeth  also  being  more  rapidly  developed  should,  we  might 
naturally  expect,  show  less  power  of  resistance  than  their  more  slowly  developed 

Fig.  12.  Fig.  13. 


Upper  jaw  with   portions  of  the  roots  of  tcni-  Lower  jaw  witli  lower  second  lomporary 

porary  central  incisors  exposed.  molar   having   one  root  fully   and   one   root 

partially  exposed. 

successors,  whilst  a  proportionately  larger  pulp  cavity  would  result  in  an  earlier 
exposure  of  its  contents,  and  an  earlier  death  of  the  tooth. 


DISEASES    OF    TEMPORARY    TEETH.  43 

speedily  detach  the  tooth  ;  witli  the  removal  of  the  tooth  the 
ulceration  and  swellino^  soon  disappear,  although  the  small 
cicatrix  above  mentioned  ma}'  result.  [Excision  of  the  exposed 
ends  of  the  roots,  and  their  subsequent  smoothing  by  a  file,  have 
resulted  in  very  happy  healing  and  restoration  of  the  utility  of 
such  teeth  in  the  writer's  }>ractice.] 

The  treatment  of  caries  of  the  iirst  teeth  will  be  conducted 
upon  much  the  same  princij)lcs  as  will  be  detailed  when  we 
treat  of  that  disease  in  the  permanent  set:  we  cannot,  however, 
too  strongly  inculcate  an  early  employment  of  the  tooth-brush, 
especiiiUy  at  night:  parents  are  commonly  disposed  to  imagine 
that  practice  unnecessary  with  children,  and  the  latter  suffer 
accordingly.  In  the  case  of  superficial  caries,  where  the  opera- 
tion of  filling  cannot  be  resorted  to,  the  cleansing  process  be- 
comes imperative:  it  should  be  performed  after  each  meal,  and 
a  few  drops  of  a  mixture  of  sal  volatile  and  alcohol^  applied  at 
the  conclusion.  When  this  is  persevered  in,  the  progress  of  the 
caries  seems  to  be  generally  arrested,  and  the  teeth  affected  are 
often  preserved  until  the  ordinary  time  for  shedding  them 
arrives.  Moreover,  the  teeth,  which,  when  affected  with  the 
superficial  decay,  are  usually  very  sensitive  to  bite  ui)on,  become 
with  this  treatment  free  from  tenderness  and  useful  in  masti- 
cation. [Lime-water  diluted  with  three  or  four  parts  of  water 
makes  an  excellent  local  aj)plication  or  mouth-wash  ;  and  pre- 
pared chalk,  rubbed  around  these  teeth  with  the  finger,  and 
allowed  to  remain  during  the  night,  will  afford  relief,  and  often 
by  neutralizing  acid  conditions  effect  a  cure.] 

The  temporary  teeth,  having  fulfilled  their  ofiice,  retire  from 
active  service  in  favor  of  their  more  durable  successors.  "Whe- 
ther the  act  of  their  departure  jiertains  more  to  themselves  or 
to  their  successors  has  been  for  some  years  a  moot  point.  An 
ancient  view  was  tliat  the  permanent  teeth  in  their  advance 
absorbed  and  assimilated  for  their  own  benefit  their  temporary 
predecessors,  and  in  this  cannibal  view  perhaps  a  modicum  of 
truth  existed.      A    more   recent   view   regards   the  temporary 

'  ^.  Spiritus  ainmonife  aromat.  ,5J  ; 
Spiritus  vinse,  ^iij  ; 
M.  ft.  applicatio. 
About  10  drops  of  the  above  to  a  teaspoonful  of  water  to  be  applied  ou  the 
tooth-brush  after  cleansinE:  the  teeth. 


4i     MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

teeth  as  subject  to  that  condition  which  appertains  to  all  tissues 
of  the  body — cells,  fibres,  and  their  combinations,  even  to  the 
whole  body  itself,  viz.,  in  having  a  fixed  period  of  existence, 
which  includes  the  stages  of  development  and  growth,  of  main- 
tenance and  maturity,  and  of  degeneration  and  decay,  in  wdiich 
last  they  undergo  changes  which  involve  their  being  cast  off 
from  the  surface  like  hair,  epithelia,  etc.,  or  breaking  up  and 
being  carried  away  in  the  circulatory  system,  as  are  all  sub- 
cutaneous tissues  in  the  body  ;  and  to  this  rule  the  fangs  of  the 
temporary  teeth  form  no  exception  :  they  also  undergo,  at  fixed 
periods  of  their  existence,  ramollissement,  and  are  removed 
amongst  the  products  of  metamorphosed  tissues.  Whilst  we 
are  full}'  prepared  to  admit  the  truth  of  this  doctrine,  in  so  far 
as  that  a  change  in  the  condition  of  a  temporary  tooth  precedes 
its  absorption,  it  is  yet  evident  that  the  process  is  closely  in 
relation  with  that  which  eft'ects  the  eruption  of  its  successor; 
for,  should  the  latter  be  absent,  the  process  often  does  not  take 
place  for  many  years  later ;  indeed,  it  is  not  uncommon  to  see 
temporary  teeth  in  the  mouth  and  firm  after  maturity  has  been 
attained.  The  writer  once  filled  a  lower  second  temporary 
molar  with  gold,  in  the  person  of  a  gentleman  above  sixty. 

As  this  process  of  absorption  is  so  closely  connected  with  the 
eruption  of  the  permanent  teeth,  we  may  here  give  our  views 
upon  the  latter  process,  which  were  first  expressed  in  a  course 
of  lectures  delivered  at  St.  Bartholomew's  Hospital  in  1867,  and 
published  subsequently,  but  certaiidy  not  until  after  almost 
similar  views  had  been  exi)ressed  in  an  admirable  paper  in  the 
'•  Vierteljahrsschrift,"  by  the  pen  of  Herr  Robert  Baume.^  To 
account  for  the  eruption  of  the  teeth,  two  views  have  until  re- 
cently been  advanced  :  one,  in  which  the  process  is  attributed 
to  the  growth  of  the  fangs  of  tlie  teeth  causing  their  crowns  to 
be  raised  out  of  their  alveoli ;  and  the  other,  in  which  that  pro- 
cess is  attrihuted  to  a  growtii  of  bone  at  the  lower  portions  of 
the  alveoli,  srpieezing,  as  it  were,  the  teeth  out  of  their  sockets. 
The  first  is  still  the  view  entertained   by  some,^  but  its  inaccu- 

'  Trtinslatf'd  in  tlip  Montlily  Review  of  Dental  Surgery,  vol.  i. 

2  "  The  erui)tion  of  the  teeth  is  a  process  of  gradual  elongation  of  the  teeth 
on  the  one  hand,  and  of  simultaneous  absorption  of  the  superimposed  tissues 
on  the  other.  The  absorption  commences,  first  in  the  overhanging  margins 
and  front  -walls  of  the  alveoli,  which  gradually  disappear  until  room  is  afforded 


THE    SECOND    DENTITION. 


45 


racy  is  readily  verified  upon  the  examination  of  preparations  at 

various  periods  in  the  second  dentition.     In  the  woodcut  helow, 

taken   from  a  normal  prepara-  „.     ^ , 

Fiff.  14. 
tion    in    tlie    Museum    of    the 

Odontological  Society,  will  be 
seen  a  bicuspid  tooth,  with  the 
fang  fnlly  formed,  yet  not 
erupted,  and  other  teeth,  the 
fangs  of  which  are  nearly  com- 
pleted, also  not  erupted,  but 
which  undoubtedly  would  have 
been  so  in  due  course  had  the 
individual  survived.  For  the 
second  and  later  assigned  cause 
there  is  actually  no  ground,  as 
it  cannot  be  shown  that  there 
is  greater  development  of  bone 
taking  place  during  the  erup- 
tion of  the  teeth  at  the  apices 
of  the  alveoli  than  at  other 
parts  of  that  district  of  the 
maxillae. 

[A  remarkable  case  was  exhib- 
ited by  Dr.  George  W.  Neidich, 
before  a  meeting  of  the  Pennsylvania  State  Dental  Society,  of 
a  young  gentleman  with  a  central  incisor  presenting  a  corner 
of  its  cutting  edge  under  the  mucous  membrane  of  the  gum 
near  the  freenum  of  the  lip,  and  its  root  at  the  length  of  the 
tooth  back  in  the  palate.  It  was  treated  by  him,  and  the  tooth 
brought  down  to  a  normal  position,  save  that  it  was  con- 
siderably twisted  upon  its  longitudinal  axis  and  presented  the 
mesial  face  to  the  front.  A  cliange  of  residence,  by  removal  of 
the  family,  caused  him  subsequently  to  come  under  the  writer's 
care,  and   the  tooth  gave  every  evidence  of  being  sound  and 

for  the  free  passage  of  tlie  advancing  tooth.  The  growth  of  the  tooth  keeps 
pace  witli  this  absorption,  and  the  crown  at  length  pressing  against  the  mem- 
branous coverings,  these  undergo  atrophy,  and,  becoming  by  degrees  thinner 
and  at  last  transparent,  give  way  and  disclose  the  advancing  crown." — The 
Student's  Guide  to  Dental  Anatomy  and  Surgery,  by  Henry  Sewell,  M.Ii.C.S., 
187G,  p.  27. 


Upper  maxilla  of  the  right  side,  -nith  por- 
tions cut  away  to  exhibit  the  developing  per- 
manent teeth.  It  will  be  observed  that  the 
fang  of  the  first  bicuspid  is  fully  developed, 
and  the  fangs  of  the  cuspidatus  and  second 
bicuspid  are  nearly  so,  while  no  portion  of  the 
crown  of  these  teeth  has  been  erupted.  The 
platform  of  bone  spoken  of  in  the  text  is  se^n 
supporting  the  first  temporary  molar. 


46  MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

healthy,  altliono-h  tlie  apex  had  traversed  one-half  to  three- 
quarters  of  an  inch  through  the  bone.  This  remarkable  opera- 
tion, aside  from  the  wonderful  perseverence  and  endurance  on 
the  part  of  both  the  dentist  and  the  patient,  with  the  consum- 
mate skill  and  intimate  knowledge  of  the  former,  shows  that 
it  is  possible  for  the  nutrient  vessels  and  nerve  filaments  of 
the  apex  of  the  root  to  follow  it  through  the  bone  and  accom- 
modate themselves  to  new  positions  widely  distant  from  their 
original  ones. 

The  final  history  was  confirmative  of  the  above  diagnosis. 
The  patient  preferred  to  take  the  risk,  of  immediate  torsion 
detaching  the  vessels  and  devitalizing  the  pulp,  rather  than  the 
slow  and  almost  sure  but  more  painful  methods;  indeed  it  was 
the  only  operation  to  wdiich  he  would  submit,  although  the 
danger  to  this  [larticular  tooth  was  fully  explained  to  him. 
The  tooth  was  then,  by  several  o[)erations  of  immediate  torsion 
with  forceps,  as  recommended  by  Tomes,  brought  into  proper 
position,  but,  as  already  intimated,  the  pulp  died  and  was 
treated  accordingly.  With  but  slight  change  of  brilliancy  it 
remained  at  his  last  visit  to  me  })erfectly  serviceable,  although 
several  years  had  elapsed  since  devitalization  of  the  pulp.  I 
may  add  that  tliis  is  the  only  case  of  death  of  pulp  following 
that  operation  in  my  practice,  although  I  have  repeatedly  per- 
formed it.] 

The  only  probable  explanation  which  it  appears  to  us  can  he 
oftered,  is  in  the  general  growth  and  advance  of  the  bone 
towards  the  surface,  carrying  with  it  the  contained  teeth. 

This  assertion  consequentlj'  im|»lies  a  continual  growth  of 
bone  (as  is  the  case  with  epitlielia,  cartilage,  etc.  etc.)  from  its 
nutrient  centres  towards  its  circumference,  and  also  that  at  the 
latter  aljsorption  must  be  frequently  taking  place,  as  we  have 
evidence  of  its  occasionally  doing  during  the  process  of  absorp- 
tion of  the  temporary,  and  advance  of  the  permanent,  teeth, 
where  portions  of  bone — platforms,  as  they  might  be  called, 
supporting  the  former— are  often  seen  extending  much  beyond 
the  general  level,  as  represented  in  tiie  woodcut;  which  plat- 
forms become  absorbed  as  soon  as  the  sustained  teeth  fall  out. 
To  which  tissue  or  structure  this  power  of  absorptioji  pertains, 
we  will  not  venture  to  decide;  thougli  we  are  inclined  to  the 
conclusion  that  it  is  effected  by  the  osteo-blastic  layer  of  the 


THE    SECOND    DENTITION.  47 

periosteum  assuming  an  osteo-clastic  function.  But  that  such 
power  exists,  none  we  think  can  deny  from  the  foi'egoing  con- 
siderations, as  also  wlien  we  take  into  account  those  conditions 
of  loss  at  certain  })arts  and  gain  at  others  which  take  place  in 
the  inferior  maxilla  between  childhood  and  manhood  ;  more- 
over, it  affords  a  more  rational  explanation  of  the  exfoliation  of 
teeth  and  roots,  when  unopposed  by  pressure,  also  of  sequestra 
of  bone,  than  the  assertion  that  nature  casts  such  off  because  use- 
less. In  the  treatment  of  irregularity  in  position  by  mechanical 
appliance,  we  often  see  certain  teeth,  wliich  have  been  relieved 
from  opposing  pressure  by  such  means,  become  unduly  elon- 
gated ;  whilst  in  cases  where  a  tooth,  from  loss  of  its  comrades, 
becimies  subjected  to  undue  pressure,  it  will  be  found  often  more 
deeply  imbedded  in  the  jaw  than  is  natural.  According  then 
to  the  views  advanced,  a  tooth  developed  in  the  maxilla  is 
carried  with  the  growth  of  that  bone  towards  the  surface. 
Arriving  at  the  surface,  the  bony  c(wering  becomes  absorbed, 
and  the  more  so  as  the  tooth  advances,  until  the  crown,  project- 
ing above  the  surface,  meets  with  some  0[)position  to  its  further 
advancement,  and  is  retained  in  position,^  when  the  bone  imme- 
diately surrounding  it — its  alveolus — becomes  more  dense  in 
character,  and  less  ra[)id  in  growth,  than  the  surrounding  can- 
cellous interalveolar  portions.  The^^e  harder  portions  of  bone 
being  more  stationary,  we  have,  doubtless,  so  to  speak,  bone 
currents  continually  existing  in  the  maxillfe,  but  more  especially 
during  the  periods  of  the  first  and  second  dentitions,  when  these 
bones  are  in  a  condition  of  more  than  ordinary  active  develop- 
ment.^ If  we  now  apply  these  views  to  the  question  before  us, 
viz.,  the  absorption  of  the  temporary  teeth,  we  shall  understand 
that  the  bone,  carrying  with  it  the  permanent  teeth,  advances 
to  the  surface,  where  it  becomes  absorbed  ;  and,  as  this  process 
of  absorption  must  at  these  times  be  very  active  and  extensive, 

'  Besides  the  operation  of  opposing  teeth  in  effecting  sucli  retention,  we  may 
take  into  consideration  the  retaining  power  exercised  by  tlie  mucous  membrane 
firmly  attached  to  the  necks  of  the  teeth,  which  attachment,  when  lost  by 
disease,  is  almost  invariably  followed  by  their  exfoliation. 

2  These  views  have  been  more  fully  expressed  in  a  contribution  to  the  St. 
Bartholomew' s  Ho^piUd  Reports,  p.  91.  They  have  met  Avitli  the  approval  of 
Professor  Owen,  who  has  kindlj'  pointed  out  to  the  writer  a  similarity  of  idea 
in  his  description  of  the  development  of  teeth  in  the  elepliant,  OdontograpJii/, 
p.  639  ;  but  C.  S.  Tomes  still  regards  the  process  as  obscure  and  unexplained. 


48  MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

ns  indeed  we  know  it  to  be,  it  seems  probable  tbat  the  periosteal 
covering  to  the  temporary  teeth  meets  the  same  fate,  or  becomes 
80  altered  in  character  that  its  osteo-blastic  elements  may  become 
active  and  osteo-clastic  agents.  In  either  way,  it  so  happens 
that  the  fangs  of  the  teeth  come  into  contact  with  these  ele- 
ments, which  are  found  in  collections  about  their  roots,  and 
constitute  the  "absorption-organs  of  Tomes."  la  confirmation 
of  the  position  taken  above,  we  have  the  fact  that  there  is  no 
ai>pearance  of  periosteum  where  the  process  of  absorption  is 
taking  place.  These  cells,  the  elements  of  absorption,  are  in 
no  wise  difterent  from  those  of  actively-growing  bone  ;  indeed, 
J,  Tomes  shows  that  the  process  of  absorption  is  often  alter- 
nating with  that  of  formation,  but,  the  balance  being  in  favor 
of  the  former,  the  greater  part  of  the  dentine,  and  generally 
some  portion  of  the  enamel,  eventually  disappears.  It  is  not 
uncommon  to  see  a  temporary  tooth,  esj»ecially  a  molar,  at  the 
period  of  its  being  shed,  appearing  of  a  pink  color,  owing  to  its 
transparency,  showing  through  it  the  vascular  and  proliferating 
bone-elements  beneath  it.  The  condition  termed  necrosis,  in 
which  a  tooth  or  bone  has  undergone  changes  other  than  a 
mere  loss  of  vitality — which  is  not  the  case  with  simply  dried 
teeth  or  bone  removed  from  living  or  recently-killed  animals, 
where  chemical  change  or  decomposition  has  not  ensued — is  a 
barrier,  and  fortunately  so,  to  the  i)roces8  of  absorption,  such 
tooth  or  sequestrum  being  got  rid  of  by  the  general  advance  of 
bone  to  the  surface;  but,  where,  through  resistance  by  obstacles, 
etc.,  necrosed  temporary  teeth  or  roots  are  retained  m  situ,  they 
form  a  common  cause  of  irregularity  in  their  permanent  suc- 
cessors. [Sometimes,  however,  a  process  of  erosion  of  these 
dead  roots  takes  place,  and  they  are  removed  or  exuviated 
with  but  little  irregularity  as  to  time  or  manner.] 

But,  whatever  be  the  means,  the  absorption  of  the  temjiorary 
teeth  is  so  far  effected  that  they  lose  their  hold  upon  the  mucous 
membrane,  and  fall,  or  are  rubbed  off,  from  it:  the  order  of 
their  disappearance  is  usually  that  of  tlie  appearance  of  their 
successors.  The  process  is  happily  a  gradual  one,  otherwise 
animals  would  be  left  for  a  time  in  an  unpleasant  predicament, 
and  it  usually  occupies  about  ten  to  twelve  years  or  even 
longer.  [Generally,  in  this  country',  the  eleventh  or  twelfth 
year  finds  the  process  completed  so  far  as  the  replacement  of  the 


THE    SECOND    DENTITION. 


49 


deciduous  teeth  is  concerned.]  In  most  cases,  the  falling  out  of 
a  tooth  is  followed  by  the  a[)pearance  of  its  successor  within  a 
few  days ;  in  some,  the  successor  api>ears  before  the  predecessor 
has  departed,  and  then  in  an  abnormal  position  ;  and  in  some 
it  does  not  ap[)ear  for  months  or  even  years  after. 

The  teeth  of  the  permanent  set  are  thirty-two  in  number: 
they  therefore  contain  in  their  series  twelve  more  than  the 
temporary  set.  They  are  arranged  in  the  same  manner,  viz., 
an  equal  number  in  each  jaw,  and  symmetrically  on  each  side 
of  the  mesial  line  of  the  month. 

Their  formula  is  incisors  |,  cuspidati  ^,  bicuspids  |,  molars  f ; 
the  cuspidati  are  also  called  canine  and  eye  teeth,  and  tlie  bi- 
cuspids premolars.  [The  cuspids  of  the  lower  jaw  are  frequently 
called  "stomach  teeth,"  in  contradistinction  to  those  of  the 
upper.] 

The  first  permanent  tooth  that  makes  its  appearance  is  the 
first  molar,^  and  it  is  generally  the  largest  in  size  of  all.     When 

Fis:.  15. 


Upper  permanent  teeth  of  the  left  side.     «,  central  incisor  ;  6,  lateral  incisor  ;  c,  cuspidatus; 
d,  first  bicuspid  ;  e,  second  bicuspid  ;  /,  first  molar  ;  g,  second  mular  ;  k,  third  molar. 

the  second  temporary  molar  has  been  ei'upted,  it  almost  wholl}' 
occupies  the  space  between  the  first  molar  and  the  coronoid 
l)rocess  of  the  lower  and  the  tuberosity'  of  the  upper  jaw  ;  but, 
as  the  period  of  tlie  second  dentition  approaches,  considerable 


'  This  tooth  holds  a  somewhat  sin2;ular  position  in  the  dental  series.  In 
regard  to  its  development,  it  is  closely  allied  to  the  temporary  series,  in  having 
its  formation  from  a  special  duplication  of  the  mucous  membrane,  and  in  not 
being  any  offshoot  from  a  temporary  tooih,  and  also  in  its  furnishing  the  off- 
shoots for  the  second  and  third  molars.  From  the  age  at  which  it  is  erupted, 
and  from  its  not  undergoing  absorption,  and  its  iiot  having  a  successor  in  its 
place,  also  from  its  position,  etc.,  in  the  series,  it  is  classed  amongst  the  second 
or  permanent  teeth  ;  its  claim,  however,  to  permanency  in  another  sense, 
especially  in  the  present  day,  is  a  very  doubtful  one. 
4  * 


50 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


space  will  be  found  to  exist  posterior  to  those  teeth,  which  is 
produced  in  the  lower  jaw  by  an  absorption  or  loss  of  bone  at 
the  anterior  and  inferior  portions  of  the  coronoid  processes, 
with  corresponding  increase  at  the  posterior  and  inferior  por- 


F\<r.    16. 


Lower  permanent  teeth  of  the  right  side,      a,  central  incisor  ;   6,  lateral  incisor  ;   c,  cuspidatus  ; 
d,  first  bicuspid  ;  c,  second  bicuspid  ;  /,  first  molar  ;  g,  second  molar  ;  Ji,  third  molar. 


tions  of  the  ascending  rami;  and  is  produced  in  the  upper  jaw 
by  additions  to  the  tuberosities;  and  this  process,  mainly 
dependent  upon  the  presence  of  developing  teelli,  is  continued 
until  room  sufficient  is  atforded  for  two  more  large  teeth  behind 
the  first  permanent  molars,  viz.,  the  second  and  third  of  the 
same  name:  a  want  of  such  due  development  is  often  the  cause 
of  a  form  of  irregularity,  attended  by  very  distressing  condi- 
tions. [There  is  also  a  marked  growth  of  the  anterior  portion 
of  the  superior  maxilla  at  the  intermaxillary  bones,  which 
enlarges  the  arch  formed  by  the  oral  teeth,  and  the  adult  inferior 
maxilla  is  increased  in  size  less  markedly,  but  at  the  correspond- 
ing portion.]  The  first  permanent  molars  generally  make  their 
appearance  between  the  years  of  six  and  seven,  and  the  next  in 
order  are  the  central  incisors  of  the  lower  jaw  ;  but  the  follow- 
ing table  will  convey  fairly  the  periods  of  eruption  for  all,  and 
will  probably  be  easier  for  recollection  : — 

YEARS 

1.  First  molars 6 

2.  Central  incisors,  lower  jaw 7 

3.  Central  incisors,  upper  jaw 8 

4.  Lateral  incisors,  both  jaws  (lower  preceding  upper)  9 

5.  First  bicuspids 10 

6.  Second  bicuspids 11 

7.  Cuspidati 12 

8.  Second  molars 13 

9.  Third  molars 17  to  20 


THE    SECOND    DENTITION.  61 

[These  ages  are  likewise  too  advanced  for  this  country.  The 
permanent  teeth  are  in  their  eruption,  like  the  deciduous  teeth, 
subject  to  great  variation.  An  allowance  of  about  one-sixth 
may  be  made  for  the  first  molars,  they  being  often  erupted  at 
five  years  of  age.] 

That  the  second  dentition  should  be  accomplished  under  much 
more  favorable  conditions  than  are  usual  with  the  first,  has, 
when  we  consider  the  size  of  the  permanent  teeth  and  their 
irregular  positions  during  development,  been  a  matter  of  sur- 
prise, and  has  led  to  various  explanations  to  account  for  it. 
That  which  appears  to  us  the  most  satisfactory  attributes  it  to 
the  peculiar  condition  of  the  nervous  sj'stem  at  the  period  of 
the  first  dentition,  and  when  the  nervous  apparatus  is  under- 
going a  condition  of  development  incomparably  greater  than 
occurs  at  any  other  period  of  life.^ 

Although  the  second  dentition  may  be  regarded  with  differ- 
ent feelings  from  those  with  which  we  estimate  the  first,  yet  it 
occasionally  happens  that  conditions  present  themselves  which 
we  must  be  careful  not  to  overlook.  Thus,  independently  of 
any  special  symptoms,  a  child  during  the  second  dentition,  and 
especially  during  the  eruption  of  the  molars,  may  appear  want- 
ing in  its  usual  spirits,  sometimes  suffering,  though  not  severely, 
with  headache,  or  slight  neuralgic  pains,  and  the  appetite  is  not 
unfrequently  either  diminished  or  capricious.  Such  symptoms 
are  most  commonly  met  with  when  the  second  molars  are  being 
erupted,  and  they  are,  though  no  doubt  much  influenced  by, 
often  attributed  wholly  to,  the  period  of  puberty  having  arrived. 
[The  faculty  of  speech  is  now  well  established,  and  we  not  infre- 
quently find  the  child  complaining  of  the  discomforts  of  teeth- 
ing. After  one  experience  of  the  trifling  pain  of  lancing  and 
the  great  relief  from  it,  a  reiietition  of  the  operation,  over  the 
remaining  second  molars,  is  not  uncommonly  demanded  by  the 
patient.]  Other  conditions,  more  especially  pertaining  to  the 
nervous  system,  may  frequently  be  manifested  at  this  period, 
and  dental  influence  may  be  witnessed  by  the  symptoms  lessen- 
ing when  the  teeth  become  erupted,  and  of  these  chorea,  quite 
independent  of  rheumatic  origin  or  influence,  is  not  an  uncom- 

'  West,  op.  cit. 


52     MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

men  one;  also  those  tricks  of  nervous  movements,  which  often 
become  habitual  when  the  cause  that  produced  them  no  longer 
exists.  With  history  of  or  tendency  to  epilepsy  the  period  of 
the  second  dentition  is  one  of  importance  and  anxiety,  especially 
during  that  of  the  eruption  of  the  third  molars.  Several  such 
cases  have  come  under  our  notice,  and  in  more  than  one  of  them 
marked  benefit  has  followed  their  removal,  as  soon  as  it  was 
possible  to  accomplish  it. 

The  local  conditions,  though  generally  less  marked  than  in 
the  first  dentition,  may  at  times  demand  attention.  It  is  not 
uncommon  to  find  children  complaining  of  pain  when  they  eat, 
and,  on  inspecting  the  mouth,  to  find  the  gums  so  swollen  over 
the  coming  first  molars  that  the  mucous  membranes  of  each  jaw 
meet  and  are  pressed  upon  when  the  mouth  is  closed.  Soothing 
applications  will  generalh'  reduce  the  swelling,  and  with  it  the 
cause  of  discomfort ;  more  rarely  the  gum  may  appear  white  in 
color,  and  evidently  stretched  over  the  cusps  of  a  molar  tooth  ; 
here  the  gum-lancet  will  s[ieedily  relieve.  It  is  in  the  eruption 
of  the  third  molars,  however,  that  most  pain  and  discomfort  are 
usually  experienced,  and  even  at  times  when  ample  room  for 
them  exists,  and  where  there  is  no  undue  distension  of  the  gum, 
as  is  manifested  hy  a  small  probe  being  easily  passed  between  it 
and  the  tooth  ;  the  surrounding  gum,  too,  becomes  often  acutely 
inflamed,  swollen,  and  even  ulcerated;  the  pain  is  not  confined 
to  the  spot,  but  is  felt  in  the  ear,  running  up  to  the  vertex,  and 
down  at  times  as  far  as  the  clavicle  ;  not  unfrequently  tlie  in- 
flammation extends  to  the  tonsil  of  the  aftected  side.  For  this 
condition  we  have  found  a  solution  of  chlorate  of  potash  in 
poppy  fomentation  an  excellent  and  most  efi:ectual  remedy;^  it 
seems  more  certain  than  any  we  know  of,  for  reducing  the  tris- 
mus often  so  severe  and  trying  in  these  cases. 

Matter  occasionally  forms  at  or  near  the  roots  of  third  molars, 
hut  we  shall  refer  to  these  conditions  when  speaking  of  irregu- 
larities in  position  of  the  permanent  teeth. 

[Extraction  of  the  third  molar  may  be  demanded  to  relieve 

'   R.  Potassa;  chloratis  ^iss. 
ft.  pulv.  xij. 
To  one  ounce  of  warm  poppy  foinpntulion  add  one  of  the  powders  and  foment 
the  inside  of  the  mouth. 


THE    SECOND    DENTITION.  53 

these  cases.  Sometimes  the  second  molar  is  tlie  tooth  whose 
removal  gives  the  most  immediate  relief;  but  where  the  first 
molars  are  very  defective,  and  the  second  comparatively  intact, 
the  removal  of  the  former  is  generally  preferred,  as  nature  will 
usually  move  the  twelve-year  molar  forward  unless  it  be  locked 
in  its  place  by  occlusion  with  its  antagonist  of  the  other  jaw  ;  a 
condition  which  seems  to  make  its  extraction  instead  of  the 
first  molar  preferable.] 


54 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


CHAPTER    III. 

IRREGULARITIES  IN  THE  PERMANENT  TEETH. 

Irregularities  in  the  permanent  teeth  constitute  a  very  im- 
portant department  in  dental  surgery.  We  shall  consider  them 
under  the  same  heads  as  we  arranged  them  in  the  temporary 
series. 

1.  In  size:  here  we  have  great  variation  independent  of  any 
pathological  imperfection.  In  the  following  cuts  are  shown  the 
central  incisors  of  the  upper  jaw,  actual  size  from  a  cast  in  the 
possession  of  S.  Cartwright ;  also,  for  comparison,  the  same  teeth 
abnormally  small  but  free  from  any  pathological  defects. 


Fig.  17. 


Ficr.  18. 


Permanent  teeth  of  unusuaUy  large  dimensions, 
copied  from  a  cast  in  tlie  possession  of  S.  Cart- 
wright,  actual  size. 


Permanent  teeth  of  unusually  small 
dimensions,  copied  from  a  male  patient 
of  the  writer's. 


Malformed  supernumerary  teeth  are  often  met  with,  of  very 
small  size  ;  probably  the  smallest  on  record  are  those  in  the 
museum  of  the  Odontological  Society,  attached  to  which  is  a  very 
interesting  history.^     A  not  unusual  condition  of  things  is,  to 


'  Thfy  occurred  in  the  mouth  of  a  nurse  in  one  of  the  wards  for  syphilitic 
patients  at  St.  Bartholomew's  Hospital,  who  frequently  had  to  perform  mer- 
curial inunction,  and  who  had  been  often  in  consequence  salivated,  and  had 
lost  all  her  permanent  teeth.  Some  years  after  she  had  lost  her  second,  there 
a])pc'ared  at  times  on  the  mucous  membrane  of  the  mouth  very  minute  mal- 
formed teeth  not  larger  than  a  No.  G  shot,  which  were  regarded  as  teeth  belong- 
ing to  a  third  set.  We  can  liardly  doubt  but  that  they  were  teeth  developed  in 
a  deutigerous  cj'st,  such  as  have  been  described  by  Carl  Tellander,  of  Stock- 
holm, and  Mathias,  of  India.     [The  writer  remembers  having  seen  intheprac- 


IRREGULARITIES    IN    PERMANENT    TEETH.  55 

see  one  of  the  upper  lateral  incisors,  or  sometimes  both,  small 
and  conical  in  the  crown,  resembling  the  commonest  type  of 
supernumerary  tooth,  and  especially  is  this  the  case  when  one  of 
these  teeth  may  be  wanting.  It  indicates  that  the  tooth  has 
appeared  in  its  most  rudimentary  form,  a  stage  just  beyond 
not  appearing  at  all.  The  teeth  which  vary  most  in  size  are 
probably  the  third  molars ;  the}' sometimes  present  themselves 
on  the  lower  jaw,  quite  one-third  larger  than  the  second  molars, 
appearing  almost  as  if  they  were  a  combination  of  themselves 
with  a  smaller  tooth,  whilst  in  the  upper  jaw  especially  they 
may  appear  quite  rudimentary  in  form,  like  the  small  u[»per 
incisors  alluded  to. 

In  the  treatment  of  these  cases  we  do  not  interfere  unless  the 
deformity  caused  is  very  unsightly.  In  a  case  where  the  upper 
central  incisors  were  out  of  all  proportion  in  excess  of  size  over 
the  other  teeth,  and  projected  over  the  lower  lip,  giving  to  the 
individual  a  strongly  rodent  expression,  we  removed  them  and 
succeeded  in  bringing  the  laterals  together,  so  as  to  quite  close 
up  the  gap.  [Sometimes  such  teeth  may  be  cut  down  to  a  more 
sightly  size  by  means  of  files  or  revolving  discs  and  points  upon 
the  burring  engine,  in  which  case  after  they  are  polished,  they 
may  last  for  a  long  service.  In  extreme  cases  pivoting  will  be 
preferable  to  extraction,  but  both  this  and  the  cutting  down  are 
only  serviceable  where  the  roots  are  firm  in  their  alveoli,  and 
tolerably  healthy,  which  is  not  always  found  to  be  the  case, 
especially  where  the  trouble  is  from  hypertrophy  of  the  cemen- 
tum  or  surrounding  tissues.]  "VVe  have  often  also  in  young 
persons  removed  with  advantage  one  or  both  of  the  unsightly 
diminutive  laterals  spoken  of. 

2.  In  form:  the  variations  to  which  the  permanent  teeth  are 
subject  may  be  said  to  be  almost  endless,  and  it  would  much 
exceed  the  limits  of  this  work,  as  well  as  not  fulfil  its  objects 
were  we  to  attempt  to  enumerate  them.  Amongst  the  most 
common  departures  from  the  normal  type  are  the  so-called  hone}^- 
combed  teeth,  the  enamel  of  which  has  been  so  imperfectly  deve- 
loped that  it  is  wanting,  or  almost  wanting,  at  many  parts:  it 

lice  of  his  preceptor,  Dr.  IST.  L.  Dickey,  of  New  Orleans,  in  18o9,  a  dentigerons 
cyst,  in  the  mouth  of  a  negress,  which  was  opened  by  the  extraction  of  a  molar. 
The  contained  teeth  were  about  the  size  and  appearance  of  grains  of  rice.] 


56  MANUAL    OF     DENTAL    SURGERY    AND    PATHOLOGY. 

most  commonly  takes  an  arrangement  of  parallel  horizontal 
lines  on  the  teeth,  which,  however,  are  not  equidistant  from  the 
cutting  surface  on  the  crown  on  each,  and  therefore  prohably 
correspond  to  certain  periods  in  the  development  when  those 

conditions  prevailed  which  prevented 
=•      '  the  perfect  arrangement  of  the  enamel 

fibres  or  the  deposition  of  the  lime- 
salts.  The  teeth  most  affected  are  the 
central    incisors,   cuspidati,    and    first 

Hoaeycombed  teeth  of  the  upper      moUirS.       TllC    lateral  iucisOrS    OCCasiOH- 

jaw  (from  a  cast  in  onr  possession).         .,  -  „  i        ,1 

ally  escape,  as  do  more  trequently  the 
bicuspids ;  the  second  and  third  molars  enjoy  the  greatest  im- 
munity. Jonathan  Hutchinson  attributes  this  condition  of  the 
teeth  to  being  largely  dependent  on  the  effects  of  mercury 
administered  in  infancy.  The  facts  which  he  brings  forward 
are  well  supported,  but  it  cannot  be  denied  that  tj^pical  cases 
occur  where  that  drug  has  never  been  taken,  and  we  have  over- 
whelming proof  that  it  is  inherited  from  parents.  It  is  an  un- 
sightlj'  and  disfiguring  condition,  and  our  gratitude  should  be 
accorded  to  any  who  may  endeavor  to  seek  out  its  cause  and 
means  of  prevention  or  mitigation.  [It  may  be  seen  that  the 
markings  upon  the  teeth  will  afford  a  pretty  correct  idea  of  the 
time  at  which  the  trouble  took  place, and  inasmuch  as  the  teeth 
are  dermal  appendages,  they  will  almost  invariably  be  found  to 
have  occurred  at  a  time  when  tlie  skin  or  mucous  membrane 
was  affected  by  some  disease.  The  major  exanthemata  almost 
invariabl}'  leave  traces  in  the  way  of  pittings  or  markings  on 
tlie  teeth  at  points  corresponding  to  the  jmrts  undergoing  den- 
tinification  at  the  time  the  disease  was  experienced.^  Prof.  C. 
A.  Harris  long  ago  called  attention  to  the  cause  of  odontatro- 

We  are  indebted  to  Hutchinson  also  for  having  first  called 
our  attention  to  another  very  important  form  of  this  class  of 
irregularity,  viz.  the  teeth  of  the  subjects  of  inherited  syphilis, 
which  first  attracted  his  attention  whilst  working  at  ophthalmic 
diseases.  In  recognizing  a  syphilitic  form  of  keratitis  which  had 
previously  been  regarded  as  strumous,  and  had  been  confounded 

['  Prof.  Cliapin  A.  Iliirris,  M.D.,  D.D.S.,  in  bis  "Dental  Surgery,"  p.  394. 
Lindsay  &  Blakiston,  Philadelphia,  18GG.] 


IRREGULARITIES    IN    PERMANENT    TEETH 


57 


with  the  hitter,  Hutchinson's  attention  was  directed  to  a  pecu- 
liarity in  the  permanent  teeth  of  the  syphilitic.  We  had  the 
good  fortune  at  that  time  to  be  a  colleague  of  his,  and  were  able 
to  confirm  his  conclusions,  by  which  he  has  supplied  another 
and  valuable  means  of  diagnosis  in  this  most  im[)ortant  branch 
of  pathology.  The  teeth  chiefly  affected  are  the  central  incisors, 
cuspidati,  and  first  molars  of  each  jaw;  but  the  most  marked 
are  the  central  incisors  of  the  upper  jaw ;  these  when  erupted 
are  deficient  in  enamel  at  the  central  portion,  especially  of  their 
cutting  edges, — that  portion  which  corresponds  to  the  middle 
of  the  three  centres  of  development  in  these  teeth.  This  thin 
portion  soon  becomes  worn  away,  and  then  the  teeth  have  a 
notched  appearance.  A  general  deficiency  of  substance  at  the 
cutting  edge  of  all  syphilitic  teeth  gives  to  them  a  peculiar 
conical  or  peg-shaped  form,  which  contrasts  strongly  with  that 
of  normal-shaped  teeth. 

Whilst  giving  our  fullest  adhesion  to  the  correctness  of  Hut- 
chinson's views  in  general,  we  may  yet  remark  that  we  have  in 


Fiff.  20. 


Fiar.  31. 


Syphilitic  teeth  in  upper  and  lower  jaws  as 
they  appear  when  recently  erupted. 


Syphilitic  teeth  in  upper  and  lower  jaws  which 
have  been  erupted  some  time,  and  from  which  the 
slighter  portions  at  the  cutting  edges  have  been 
worn  away. 


one  or  two  instances,  and  among  the  members  of  a  healthy 
family,  met  with  a  case  of  an  individual  in  whom  the  above- 
mentioned  type  of  teeth  existed,  and  where  we  should  have 
supposed  it  almost  impossible  that  the  cause  could  be  syphilis  ; 
yet,  the  possibility  existing,  we  are  unable  to  deny  the  fact, 
though  on  the  other  hand  it  would  be  shocking  to  suspect 
unfaithfulness  which  did  not  exist. 

The  teeth  termed  supernumerary  are  more  frequently  of 
abnormal  form  than  otherwise:  the  variations  are  too  numerous 
to  be  here  described  in  detail,  their  most  common  type  being  of 
conical  form  and  small,  more  nearly  approaching  that  of  tem- 
porary cuspidati.     In  front  of  the  central  incisors  they  are  often, 


68 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY, 


thongh  less  frequently,  large,  with  four  or  more  cusps  on  the 
crown,  like  a  small  molar,  but  having  one  root.  In  rare 
instances  they  have  the  appearance  of  being  broad  and  flat  and 
folded  upon  themselves,  and  of  thus  having  a  central  hollow 
lined  with  enamel ;  but  these,  independently  of  being  super- 
numerary, as  we  have  met  with  them  in  three  cases,  appear 
rather  to  belong  to  the  class  odontomes.     Union  or  gemination 


Ficr.  23. 


Ficr.  23. 


Supernumerary  permanent  tooth  of  the  most  Supernumerary  tooth  of  the  form  not  unfre- 

common  type.  quently  met  with  ia  the  region  of  the  upper 

central  incisors. 

of  teeth  also  exists  in  the  permanent  as  in  the  temporary  series, 
but  is  probably  less  common,  though  the  union  of  fangs  through 
cementum  is  certainly  more  so. 

Departure  from  the  ordinary  number  of  fangs  is  not  infre- 
quent, the  most  common  being  excess  of  number  in  upper  third 


Throe  spocirnnns  of  gemination.  Tliat  on  the  right,  from  a  specimen  in  our  possession,  is  an 
tipper  second  and  third  molar,  in  which  the  union  is  by  cementum  only  (probably).  Tliat  in 
the  centre  is  an  upper  lateral  incisor  and  cuspidatus  of  the  left  .side;  and  that  on  the  left  hand 
is  an  upper  lateral  and  cusjiidatus  of  the  right  side,  as  seen  from  heliind,  co]iied  from  preparations 
in  the  museum  of  the  Odontological  Society. 

molars,  these  often  having  from  four  to  six  slender  roots;  lower 
molars,  the  first  especially,  having  three  fangs,  upper  bicuspids 
the  same  number,  and  lower  cuspidati  two. 

[Some  years  since  the  writer  found  in  the  mouth  of  an  adult 
lady  the  right  inferior  second  and  third  molars  so  perfectly 
united  as  to  show  only  a  slight  fissure  at  the  point  of  union. 


IRREGULARITIES    IN    PERMANENT    TEETH.  59 

Several  bicuspids  with  trifurcation  of  the  upper  third  of  the 
root  are  in  the  museum  of  the  Tliiladelphia  Dental  College.] 

Tlie  greatest  departures  in  form  from  tlie  normal  types  appear 
in  those  irregular  masses  of  dentinal  tissue  termed  odontomes. 
They  are  doubtless  the  result  of  some  hypertrophic  conditions 
affecting  the  tooth-germ ;  and  M.  Broca,  who  has  somewhat 
deeply  investigated  the  matter,  has  divided  them  into  four 
classes,  according  to  the  periods  at  which  the  hypertrophy  has 
occurred  during  the  development  of  the  tooth.  Thus,  should 
it  occur  during  the  earliest  periods  of  development,  and  before 
any  of  the  true  structures,  out  of  which  enamel  or  dentine  are 
formed,  have  made  their  ap}iearance,  the  mass  will  resemble  a 
capsulated,  or  almost  capsulated,  fibro-plastic  tumor,  which  may 
be  shelled  out,  as  in  the  case  of  a  similar  tumor  in  other  parts, 
the  uterus  for  example.  Whether  it  is  correct  to  assume  that 
all  such  tuniors  occurring  in  the  jaws  are  of  dental  origin,  is 
certainly  ojjcu  to  discussion.  The  foregoing  constitute  Broca's 
first  class,  viz., — odontomes  einbryoplastiques. 

The  second  class,  odontomes  odontoplastiques,  are  presumed  to 
be  due  to  the  same  condition  of  hypertrophy  occurring  after  the 
development  of  the  special  formative  elements  of  the  dentine 
and  enamel — the  odontoblastic  layer  or  membrana  eboris,  and 
the  columnar  cells,  otherwise  termed  the  internal  epithelium  of 
the  enamel  organ.  In  the  course  of  the  abnormal  development 
these  structures  become  more  or  less  distended  over  the  irre- 
gular surface  of  the  growth,  and,  when  calcification  has  taken 
place,  a  large,  hard  mass  of  tooth  structures,  most  confusedly 
mixed  up  together,  results,  bearing  little  resemblance  to  a 
human  tooth.  The  chief  bulk  of  the  growth  will  be  found,  as 
would  be  presumed,  to  consist  of  secondary  dentine.  In  the 
classes  which  we  have  described,  the  tumors  appear  at  times  to 
be  representatives  of  one,  and  at  others  of  more  than  one  tooth; 
in  the  two  following  classes  they  apparently  are  always  the 
representative  of  cue  tooth  ;  but  in  all,  we  believe,  they  originate 
in  the  teeth  of  the  permanent  series. 

The  third  class,  odontomes  coronaires^^  are  presumed  to  be  due 
to  hypertrophy  arising  after  some  calcification  of  the  enamel 
and  dentine,  and  when  such  portions  are  incapable  of  distension, 

>  "Warty  teeth,"  Salter. 


60  MANUAL    OF    DENTAL    SURflERY    AND    PATHOLOGY. 

which  distension  consequently  takes  place  at  parts  as  yet  not 
calcified.  In  these,  certain  portions  of  the  tooth,  especially  its 
coronal  ones,  bear  their  normal  appearance,  or  nearly  so.  This 
class  is  b}'  far  the  most  frequently  met  with  of  an}^,  especially  if 
we  include,  as  some  have  done,  those  malformed  teeth,  usually 
supernumerary,  which  appear  as  if  a  flattened  tooth-pulp  had 
been  folded  upon  itself,  and  often,  previously  to  a  section  being 
made,  appearing  like  a  tooth  developed  within  a  tooth.  We 
think,  that  if  these  should  be  classed  at  all  as  odontomes,  they 
belong  rather  to  Broca's  second  class  than  to  the  third. 

In  the  fourth  class,  odontomes  radicidaries^^  are  comprised 
those  rare  cases  where  hypertrophy  has  arisen  after  the  calcifi- 
cation of  the  crown  of  the  tooth.  Here  the  components  will  be 
dentine  and  cementum,  or  the  latter  only:  the  mass  may  be  of 
very  considerable  size,  and  be  readily  mistaken  for  an  immense 
exostosis. 

Teeth  may  also  occasionally  be  found  with  small  nodules  of 
enamel  on  the  portions  of  their  surfaces  otherwise  covered  with 
cementum,  or  there  may  be  distinct  cusps  covered  with  enamel, 
which  project  above  the  gum  and  may  readily  be  mistaken  for 
distinct  and  supernumerary  teeth,  the  error  only  being  dis- 
covered when  their  removal  is  attempted  ;  the  main  portion  of 
the  tooth  from  which  they  spring  being  seen  to  move  with 
them.  With  our  more  accurate  knowledge  of  the  development 
of  teeth,  the  occurrence  of  these  nodules  and  offshoots  is  more 
readily  explained. 

[There  would  seem  to  be  a  tendency  to  proliferation  (but  yet 
not  a  fully  completed  formation  of  distinct  sacs  and  teeth  in 
these  cases)  somewhat  similar  to  the  development  of  the  three 
molars.] 

3.  Irregularity  as  regards  number.  We  have  spoken  of  super- 
numerary teeth  in  the  last  section  ;  they  may  be  found  iti  con- 
siderable number,  even  to  four  or  Ave  in  the  same  mouth,  and 
upon  almost  all  portions  of  the  alveolar  and  palatal  processes  of 
the  maxillae;  we  recently  saw  one,  discovered  lying  horizontally 
between  the  articulations  of  the  latter  processes,  the  crown 
pointing  backwards.  They  are  more  common  in  the  upper  thari 
in  the  lower  jaw,  and,  when  in  the  latter,  are  generally  met 

'  "Ilernia  of  the  fiuvj;''  Salter. 


IRREGULARITIES    IN    PERMANENT    TEETH, 


61 


with  in  the  neighborhood  of  the  tliird  nioljirs.  Whilst  all  excess 
above  the  ordinary  number  nmst  be  regarded  as  supernumerary, 
we  may  also  class  as  such,  irrespective  of  the  proper  number 
present,  additional    teeth    occurring    in    positions   where  they 


Fis;.  25. 


Fi-  26. 


Supernumerary  teeth  iu  the  upper  jaw  of  a  youth. 
Copied  from  a  cast  iu  our  possession. 


Supernumerary  bicuspid  of  the 
upper  jaw,  right  side. 


partake  of  the  same  type  as  their  neighbors ;  thus,  we  should 
regard  as  supernumerary  a  third  well-formed  bicuspid,  or  a 
fourth  molar,  though  its  presence  might  cause  no  actual  excess 
in  the  proper  number. 

[There  are,  however,  puzzling  exceptions  to  this  rule.  Among 
the  writer's  patients  is  a  young  gentleman,  now  a  student  of 
medicine,  who  had  six  superior  incisors  so  well  formed  as  to 
defy  attempts  to  indicate  which  were  supernumerary.  There 
are  now  remaining  tive  of  these  teeth  well  formed,  and  so 
regularly  arranged  as  to  escape  notice  except  when  attention  is 
particularly  called  to  them.] 

Deticiency  in  number  is  b}'  no  means  unusual,  and  we  may 
venture  to  express  the  opinion  that  it  is  more  common  now 
than  formerly.  The  teeth  most  commonly  absent  are  the  lateral 
incisors  of  the  upper  jaw,  and  when  one  of  these  is  wanting,  that 
present  often  assumes,  as  before  noticed,  the  small  pointed  form 
characteristic  of  a  supernumerary  tooth.  Next  in  order  of  de- 
ficiency we  would  reckon  the  lateral  incisors  of  the  lower  jaw, 
and  following  these  the  second   bicuspids  of  the  same.     The 


62 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY, 


second  bicuspids  of  the  lower  jaw  are  often  impacted  between 
the  iirst  bicuspids  and  first  molars,  and  therefore  may  be  present 
without  showing  themselves  at  all,  or  until  later  in  life,  when 
they  present  an  appearance  usually  internal  to  the  dental  arch. 

[Cases  of  retention  of  the  bicuspids  have  been  presented  in 
the  writer's  practice  where  they  did  not  come  up  to  the  line  of 
occlusion  with  their  antagonists  until  after  the  fortieth  year. 
In  these  instances  they  were  generally  held  down  by  the  inclina- 
tion towards  each  other  of  the  two  adjacent  teeth,  the  removal 
of  either  of  which  permitted  the  eruption  of  the  retarded  tooth 
to  be  completed. 

The  retention  of  the  deciduous  teeth  may  likewise  be  a  fre- 
quent cause  of  irregularity  as  to  the  time  of  eruption  as  well 
as  to  position  of  the  permanent  set.] 

We  might  perhaps  have  placed  earlier  in  the  list  the  third 
molars,  but  the  evidence  of  their  absence  is  in  many  cases  ren- 

Fiff.  27. 


Upper  jaw  in  wliich  the  lateral  incisors  have  not  been  erupted. 


dered  difficult  by  the  fact  that  the  first  permanent  molar  is  often 
regarded  as  a  tem[)orary  tooth  when  it  is  removed  at  an  early 
age,  and  the  space  so  afibrded  being  quite  occupied  by  the  second 
molar,  the  third   is   not  uncommonly  regarded  as  the  second. 


IRREGULARITIES    IN    PERMANENT    TEETH.  63 

Still  they  are  sometimes  erupted  at  so  late  a  period  in  life  that 
they  may  be  present  when  not  suspected.' 

[The  writer  has  recently  seen  two  of  the  wisdom  teetli  but 
partially  erupted  through  the  gum  in  the  mouth  of  a  patient 
fifty  years  of  age.] 

Another  form  of  excess  in  number  is  where  a  third  set  of 
teeth  is  supposed  to  have  been  erupted.  Although  every  case 
we  have  investigated,  and  they  have  been  numerous,  has  turned 
out  to  be  the  eruption  of  retarded  or  missing  teeth,  of  true  super- 
numerary teeth,  or  of  portions  of  fractured  roots  of  teeth  which 
become  in  time  carried  to  the  surface  in  the  manner  described 
at  page  46,  yet  cases  have  been  narrated  by  authorities  whose 
accuracy  and  candor  must  compel  us  to  accept  the  fact  that  a 
third  set  of  teeth  is  a  possibility. 

4.  Irregularity  in  position.  To  the  dental  surgeon  this  divi- 
sion of  the  subject  is  by  far  the  most  important  and  interesting. 
It  is  moreover  one  which  often  largely  taxes  both  his  ingenuity 
and  his  patience;  sometimes  to  be  attended  by  the  disappoint- 
ment of  failure;  but,  when  successful,  bringing  the  reward  of 
almost  unspeakable  satisfaction,  for  to  restore  to  symmetry  and 
beauty  so  important  a  feature  as  the  mouth,  when  out  of 
harmony  with  the  rest,  is  certain  to  insure  for  the  practitioner 
the  lasting  gratitude  of  the  patient  and  the  patient's  friends. 

To  attempt  to  describe  the  various  forms  of  irregularity  which 
occur  under  this  head  would  be  almost  impossible,  but  we  may, 
we  trust,  aid  the  student  by  pointing  out  their  most  common 
causes  and  the  general  principles  on  which  they  may  be  treated. 
With  this  object  we  shall  somewhat  arbitrarily  divide  them 
into  two  classes,  viz.,  those  which  we  shall  term  1,  accidental 
and  avoidable,  and  those  which  we  shall  term  2,  congenital  and 
unavoidable. 

1.  Accidental  and  avoidable.  This  form  most  commonly 
arises  from  the  persistence  of  temporary  teeth  which  from  some 
cause  have  not  undergone  absorption  of  their  roots  commensu- 
rate with  the  advance  of  the  permanent  teeth,  or  from  the  reten- 
tion of  necrosed  roots  which  do  not  undergo  absorption.     The 

'  In  a  communication  recently  made  by  Professor  Flower  to  the  Odontologi- 
cal  Society,  vide  vol.  xii.  p.  32,  that  high  autliority  classes  the  third  molars  as 
the  teeth  that  are  most  frequently  absent  in  man. 


64 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


tootli  in  coDsequence  assumes  an  abnormal  position  sometimes 
anterior  or  external  to  the  proper  dental  arch,  but  more  com- 
monly internal  to  it.  To  clearly  comprehend  this  portion  of  our 
subject,  it  is  necessary  that  we  should  understand  tlie  relative 
positions  of  the  permanent  and  the  temporary  teeth,  about  the 
age  when  the  second  dentition  commences.  If  we  take  the 
skull  of  an  individual  \vho  died  at  the  age  of,  say,  six  years, 
and  before  any  of  the  temporary  teeth  have  been  shed,  and  pare 
away  the  anterior  surfaces  of  the  alveolar  processes,  we  shall 
iind  the  following  arrangement  and  condition  of  the  teeth  to 
prevail.  Commencing  with  the  upper  jaw,  we  shall  find  the 
crowns  of  the  permanent  central  incisors  situated  on  a  higher 
plane  than  the  temporary  teeth,  with  an  inclination  directed 
more  outwards,  forming  with  the  latter  an  angle  of  fifteen 
degrees  or  thereabouts,  and,  when  they  are  erupted,  placing  them 

Fiff.  28. 


View  of  the  uppor  and  Icnvorjaws  of  a  child  aged  about  63^  years.  The  external  portions  of 
the  bones  have  been  removed  to  show  the  positions  of  the  developing  permanent  teeth  and  the 
fangs  of  Ihe  temporary  teeth.  The  bifurcation  in  the  fangs  of  tlie  upper  cuspidati  is  abnormal. 
[From  "The  Mouth  and  the  Teeth,"  liy  .1.  W.  White,  M.D.,  D.D.S.] 

in  a  more  prominent  and  consequently  a  wider  dental  arch  cora- 
metisurate  with  tlieir  larger  dimensions;  they  are  also  situated 
behind  the  roots  of  the  temporary  central  and  lateral  teeth, 
which  show  some  slight  indication  of  absorption  at  this  period, 
and  the  imjierfectly  developed  extremities  of  their  fangs  abut 
closely  upon  the  thin  os-eous  floor  of  the  nares,  whilst   their 


IRREGULARITIES    IN    PERMANENT    TEETH. 


65 


cutting;  cd2;es  reach  to  about  tlie  middle  of  tlie   roots  of  the 
temporary  incisors. 

The  cuspidati,  the  crowns  of  which  are  but  barely  developed, 
are  situated  on  a  much  higher  level  than  the  last-named,  viz., 
about  J  of  an  inch  below  the  floors  of  the  orbits  (hence  [»ro- 
bably  their  designation  eye-teeth),  and  at  the  sides  of  the  outer 
walls  of  the  nares,  the  floor  of  which  is  level  with  the  centre  of 
their  crowns.  The  infra-orbital  canals  are  about  I  in.  above 
and  external  to  their  uiidevelo[)ed  extremities.  Posterior  to 
these  latter  in  the  dental  arch,  l)Ut  situated  on  a  lower  level  and 
more  external,  are  the  first  bi(;uspids,  and  between  these  and 
the  central  incisors,  and  on  nearly  the  same  plane,  are  the  lateral 
incisors,  placed  however  internal  in  the  dental  arch  to  the 
cuspidati  and  central    incisors.     The  crowns  of  the   first  and 

Fis?.  29. 


Side  view  of  the  jaw  of  a  child  with  permanent  teeth  forming'. 

second  bicuspids  not  fully  developed  are  seen  placed  directlv 
above  and  embraced  by  the  fangs  of  the  first  and  second  tem- 
porary molars  respectively.  The  first  permanent  molars,  the 
crowns  of  wiiich  nearly  meet  their  comrades  of  the  lower  jaw, 
and  which  must  have  been  erupted  some  weeks,  have  their  fangs 
about  one-half  developed,  whilst  the  second  molars,  or  rather  the 
small  developed  portions  of  their  crowns,  hold  a  position  above, 
and  posterior  to,  the  first  molars,  with  their  masticating  sur- 
faces looking  downwards  and  backwards  towards  the  lower  i)or- 
tions  of  the  external  pterygoid  processes;  little  crypts  on  a  still 


66     MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

hiirlier  level  in  the  tuberosities  of  the  bone  show  the  position  of 
the  future  dentes  sapientife  of  the  upper  jaw. 

In  tiie  lower  jaw,  the  central  permanent  incisors,  the  fangs 
of  which  are  about  one-fourth  developed,  occupy  a  more  vertical 
position,  in  a  narrower  circle,  than  do  the  corresponding  teeth 
of  the  upper  jaw  ;  and  this  holds  good  generally  with  all  the 
teeth  of  the  lower  jaw,  but  es[)ecially  the  six  front  ones.  They 
are  situated  directly  behind  the  partial Ij^  absorbed  roots  of  the 
temporary  centrals,  and  partiall}^  behind  the  temporary  laterals, 
their  cutting  edges  having  but  a  very  thin  layer  of  bone  inter- 
posed between  them  and  the  surface.  The  cuspidati  occupy  a 
lower  plane  in  the  same  arch,  their  developing  roots  resting 
upon  the  thin  dense  portion  of  bone  which  forms  the  inferior 
surface  of  the  body  of  the  lower  maxilla,  the  roots  of  their 
temporary  predecessors  being  directly  in  front  of  them.  Between 
and  partially  behind,  the  cuspidati  and  the  centrals  are  the 
lateral  permanent  incisors,  having  directly  in  front  of  them  the 
roots  of  their  temporary  predecessors.^  The  bicuspids^  occupy 
relatively'  the  same  .position  in  the  lower  as  they  do  in  the 
upper  jaws;  as  do  likewise  the  first  molars.  The  second 
molars  have  their  developing  crowns  on  a  higher  level  than 
that  of  the  bicuspids,  with  their  masticating  surfaces  looking 
upwards  and  forwards.  Small  crypts  in  the  coronoid  processes 
denote  the  position  of  the  future  dentes  sapientias,  or  third 
molars  of  the  lower  jaw. 

From  this  description  of  the  relative  positions  occupied  b}^ 
the  permanent  and  temporary  teeth  prior  to  the  eruption  of  the 
former,  we  readily  learn  how  a  persistency  in  the  latter  through 
an  unabsorbed  root  will  effect  deviation,  and  the  direction  which 
it  will  cause  a  permanent  tooth  to  take,  when  in  the  process  of 
eruption  ;  thus,  persistence  in  the  lower  temporary  incisors  will 
of  necessity,  under  the  above-mentioned  conditions,  cause  these 
teeth  in  the  permanent  series  to  occupy  a  position  within  the 

'  In  a  prcparalioa  before  us,  small  round  holes  in  the  jaws,  immediately 
above  the  summits  of  the  lateral  incisors,  show  absorption  of  the  roofs  of  their 
bony  crypts  to  iiave  taken  place  in  advance  of  any  other  of  the  six  front  teeth. 

2  The  first  bicuspids  lie  immediately  internal  to  the  mental  foramina,  which, 
remaining  but  little  changed  in  position  during  life,  constitute,  as  shown  by 
J.  Tomes,  valuable  fixed  points  for  estimating  the  various  alterations  which 
the  inferior  maxilla  undergoes. 


IRREGULARITIES    IN    PERMANENT    TEETH. 


67 


dental  arcli.  If  it  be  a  temporary  lateral  tooth  or  root,  the  per- 
manent successor  must  appear  behind  the  permanent  central 
and  the  temporary  cuspidatus,  the  temporary  cuspidati  will  have 
the  same  effect  upon  the  permanent  ones,  whilst  persistence  of 
the  roots  of  the  temporary  molars  will  cause  the  bicuspids  to 
deviate  to  positions  either  internal  or  external  to  the  dental  arch. 

The  treatment  of  these  cases  will  be  evident,  viz.,  removal 
of  the  obstructing  teeth  or  roots.  In  the  lower  jaw  we  fre- 
quently meet  with  cases  where  the  permanent  incisors  are 
erupted  behind  the  temporary  ones;  and,  by  the  removal  of  the 
latter,    the    former    are    soon 

brought  by  the  pressure  of  the  Fig.  30. 

tongue    into    proper    ])Osition ; 
and,  in  considering   the   treat- 
ment of  irregularities  in  posi- 
tion,  we   must    ever    bear   in 
mind  the  continual  beneficial 
action  of  this  member,  as  well 
as  that  of  the  lips,  in  causing 
the  teeth  to  assume  their  nor- 
mal positions.     The  former  is 
constantly  pressing  the  lower 
teeth  outwards,  until  they  be- 
come arrested  by  the  upper  teeth  which  bite  in  front  of  them  ; 
whilst  the  latter,  by  their  elasticity,  are  continually  acting  u[)on 
the  upper  teeth  in  the  opposite  direction  ;  it  therefore  happens 
that  by  these  means  great  irregularity  is 
reduced  to  symmetry  wdien  simply  oppos- 
ing obstacles  are  removed. 

But  it  may  chance  to  happen,  in  the 
case  of  the  upper  jaw,  that  we  are  not  con- 
sulted until  the  njisplaced  tooth  or  teeth 
have   been    so   far  erupted   that   they   are 

bitten  over  l)y  the  lower  teeth  wheiiever       The  couduion  termed  par- 
the  mouth  is  shut,  resulting,  in  the  case  of    tiaiiy  underhung:  itwiube 

,      .  observed  that  the  four  inci- 

one  or  two  teeth,  in  the  subjects  being  par-    sors  of  the  lower  jaw  bite  in 
tially,  and  in  tiie  case  of  the  six  front  ones,    ^'■°°'  °^  '^«  "''"■^^  '""^"'"^ 

■^    ^  _  ot  the  upper  jaw. 

in  their  being  wholly  underhung.     It  will 

here  be  apparent  that  removal  alone  of  the  temporary  obstruc- 
tives will  be  unavailing:  a  new  and   more  serious  impediment 


Lower  jaw  in  which  the  permanent  central 
incisors  have  been  erupted  behind  the  tem- 
porary central  incisors. 


Fig.  31. 


68 


MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 


exists,  and  the  ease,  if  left  to  itself,  can  only  become  worse  and 
more  disfiguring  as  time  advances.  The  lower  jaw  becomes 
gradually  drawn  forwards,  the  angles  at  the  union  of  the  body 
and  rami  forming  more  obtuse  angles  than  the  natural  ones, 
and  the  features  characteristic  of  that  species  of  dog  in  the  com- 
pany of  which  it  was  at  one  time  considered  disgraceful  to  be 
seen.  Besides  removing  the  temporary  teeth,  we  must  employ 
means  which  will  obviate  the  closing  of  the  lower  in  front  of 
the  upper  ever}^  time  that  the  mouth  is  shut,  and  at  the  same 
time  we  may  greatly  accelerate  the  process  by  applying  pressure 
behind  the  misplaced  teeth. 

The  following,  we  believe,  will   be  found   the  simplest  and 
most  effective  manner  of  accomplishing  our  object.     We  first 

[Fig.  33. 


Upper  jaw.     Impression  cup  for  wax.] 

[Fig.  33. 


Lower  jaw.     Impression  cup  for  wax.] 


obtain  an  accurate  model  of  the  mouth,  by  means  of  an  im- 
pression or  mould  taken  in  wax,  plaster  of  Paris,  gutta-percha, 
or  the  conif)Ounds  known  as  .Stent's  and  Hind's  compositions — 


IRREGULARITIES    IN    PERMANENT    TEETH. 


69 


we  recommend  the  two  latter — and  from  this  a  casting  is  made 
in  plaster  of  Paris.  To  describe  this  more  fully,  we  obtain  a 
metal  tray  of  the  size  that  will  roughly  adapt  itself  to  that  of 
the  upper  dental  arch  of  the  patient,  and  be  inserted  without 
much  stretching  of  the  mouth.  Into  this  tray  we  put  a  suffi- 
ciency of   the  Stent's  or  Hind's  composition,  which   has  been 


Lower  jaw.     Impi.  s^i.m  cup  for  jUaster.] 

[Fig.  35. 


Upper  jaw.     Impression  cup  for  plaster.] 

thoroughly  softened  in  almost  boiling  water,  then  dried  and 
kneaded  in  the  hands  to  render  it  quite  consistent ;  a  spirit 
lam})  aiding  the  latter  process,  and  causing  it  to  attach  itself  to 
the  tray,  which  should  be  filled  evenly  to  the  level  of  its  sides. 
The  surface  being  just  rubbed  over  with  a  little  olive  oil,  we 
insert  the  tray,  which  we  are  careful  to  see  is  not  hot  enough 
to  hurt  the  lips,  into  the  mouth,  one  side  before  the  other  being 


70 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY 


Fie:.  36. 


attended  with  tlie  least  stretching,  and  then  press  it  with  its 
CO  itents  steadily  upwards  in  an  almost  vertical  direction,  and 
high  enough  to  obtain  an  impression  of  the  surfaces  of  the 
teeth  above  the  gum  and  also  of  the  whole  of  the  hard  palate. 
We  allow  it  to  remain  in  its  position  for  from  two  to  four 
minutes,  as  the  patient  can  submit,  then  bring  it  vertically 
downwards,  feeling  for  and  following  the  direction  in  which  it 
comes  the  most  readily  ;  and,  when  it  is  below  the  level  of  the 
teeth, remove  it  from  the  mouth, and  thus  we  obtain  an  accurate 
impression  of  the  portion  of  the  mouth  required.  Into  this 
impression,  when  hard,  is  poured  plaster  of  Paris  of  line  quality, 
mixed  bj-  carefully  adding  the  plaster  to  the  water,  until,  when, 
well  stirred,  it  is  of  the  consistence  of  tliick  cream.  [The  im- 
pression may  be  previously  covered  with  a  thin  coat  of  olive 
oil,  by  means  of  a  camel's-hair  brush,  to  prevent  adhesion  of  the 
model.]  We  tap  the  tray  at  every  addition,  in  order  to  allow 
the  plaster  to  go  into  all  the  smallest  depressions  in  the  impres- 
sion, and  to  get  rid  of  tlie  air-bubbles, 
and,  as  the  plaster  becomes  thick 
enough,  we  build  u[)  the  model  to  the 
height  of  one  or  two  inches  in  order 
to  give  it  strength  and  solidity.  After 
a  few  hours,  and  when  the  plaster  has 
firmly  set,  it  may  be  liekl  tray-side 
downwards  in  a  vessel  of  nearly  boil- 
ing water  until  the  composition  is  so 
softened  that  it  is  readily  removed 
from  the  plaster.  The  model  is,  after 
being  trimmed,  now  transferred  to  an 
oven  and  dried  until  it  almost  ceases 
to  steam,  when,  to  render  it  hard,  it  is 
immersed  in  a  vessel  of  melted  stearine, 
and  boiled  in  it  about  half  a  minute, 
and  then  removed  to  dry.  We  have  dwelt  upon  this  process 
of  taking  impressions  of  the  mouth  becau^e  it  is  not  merely 
apjdicable  in  dental  cases,  but  may  also  be  of  use  in  many 
ordinary  surgical  ones.  We  have  found  it  very  useful,  when 
watching  the  progress  of  certain  tumors,  or  obtaining  represen- 
tations of  them  before  removal,  or  estimating  the  extent  of 
clcft-jialate,  ^.  e.,  whether  the  case  be  more  suitable  for  surgical 


Plate  adapted  to  the  upper  jaw 
suitable  for  raising  the  bite  and 
pressing  out  the  central  incisors 
■when  bitten  over  by  the  teeth  of 
the  lower  jaw.  Behind  each  cen- 
tral incisor  is  shown  the  dovetail 
cut  into  the  plate  in  which  the 
pieces  of  compressed  deal  are  in- 
sorted,  and  which  by  swelling, 
when  they  become  moist,  press 
forward  the  teeth  they  are  in  con- 
tact with. 


IRREGULARITIES    IN    PERMANENT    TEETH.  71 

or  for  mechanical  treatment,  and  in  cases  where  a  second  opinion 
at  a  distance  may  be  sought  for  without  a  journey. 

The  model  is  now  placed  in  the  hands  of  the  mechanical 
dentist,  who  constructs  a  plate  of  metal — gold,  i)latina,  silver, 
or  dental  alloy — or  vulcanite,  which  last  we  prefer  in  ordinary 
cases.  The  plate  should  cap  over  the  bicuspids  and  such  molars 
as  are  erupted,  and  may  be  made  to  keep  up  securely,  by  our 
having  scraped  away  the  model  slightly  round,  a  very  little 
below  the  necks  of  the  teeth  capped,  and  on  their  outer  surfaces, 
where  consequently  the  plate  grasps  them  ;  the  thickness  of 
the  plate  over  these  teeth  should  just  prevent  the  front  ones 
from  meeting.  Behind  each  tooth  to  be  pressed  out  should  be 
sawn  a  space,  of  dove-tail  form,  to  be  filled  up  by  a  piece  of 
soft  deal  firewood  which  has  been  greatly  reduced  in  size  by 
pressure  for  some  hours  in  a  strong  vice,  the  compressed  surface 
of  the  wood  being  opposed  to  the  tooth.  The  plate  is  intro- 
duced into  the  mouth,  to  which  it  should  attach  itself  firmly, 
and  then  the  compressed  wood  by  absorbing  moisture  swells, 
and  the  upper  teeth,  having  now  no  obstruction  from  the  lower 
biting  in  front  of  them,  are  pushed  rapidly  outwards,  often  in 
the  space  of  a  week,  though  generally  longer,  and  are  carried 
beyond  the  lower,  so  that  on  removal  of  the  plate  they  bite  in 
front  of  them  and  cannot  return  to  their  abnormal  position.  In 
the  place  of  the  wood  a  loop  of  India-rubber,  drawn  through  a 
small  hole  in  the  plate  behind  the  tooth  to  be  pressed  out,  may 
be  employed  ;  and  is  perhaps  better  where  patients  are  unable 
to  pay  frequent  visits,  but  under  ordinary  conditions  we  prefer 
the  wood.  The  patient  should  be  instructed  to  eat  with  the 
plate  in  the  mouth,  and  to  remove  it  only  for  cleansing,  which 
should  be  done  thoroughly  after  every  meal.  In  no  case  do 
we  recommend  plates  being  tied  or  fastened  in,  as  injur}"^  may 
be  done  to  the  teeth  in  even  a  few  days  when  they  cannot  be 
removed  for  cleansing.  In  cases  amongst  the  poor,  and  where 
the  above-mentioned  treatment  cannot  be  resorted  to,  success 
is  occasionally  attained  by  continually  holding  a  paper  knife  or 
thin  piece  of  wood  so  that  it  rests  in  front  of  a  lower  tooth, 
and  behind  an  upper  that  is  bitten  over;  this  method  requires 
great  perseverance,  and  probably  succeeds  only  where  the 
patient  sleeps  with  the  mouth  open.  In  a  few  hospital  cases 
we  have,  by  the  aid   of  a  thin  elastic  rubber  band,  extended 


72     MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

round  the  head  and  across  the  face,  where  it  is  padded  witli 
wool  to  prevent  uneven  pressure,  and  then  curried  behind  the 
misplaced  tooth,  succeeded  in  drawing^  it  forwards  as  desired  ; 
in  this  and  the  last-mentioned  treatment  tliin  India-rubber, 
drawn  between  some  of  the  posterior  teeth  on  each  side,  will, 
b}'  keeping  the  mouth  from  closing,  much  aid  the  process;  but 
the  irritation  thus  occasioned  cannot  be  long  tolerated.  The 
same  retention  of  the  teeth  or  roots  ma}',  when  the  permanent 
upper  incisors,  for  instance,  are  erupted  anterior  to  them,  which 
occasionally  occurs,  cause  the  latter  to  project.  When  the  pro- 
jection is  slight,  the  pressure  of  the  upper  lip  will  generally, 
after  the  removal  of  the  obstruction,  bring  matters  right;  but, 
when  it  is  more  prominent,  they  come  to  rest  upon  the  lower 
lip,  and  thus  meet  with  a  continual  agency,  in  the  form  of  an 
elastic  cushion,  to  further  projection.  For  such  cases  we  may 
employ  a  somewhat  similar  j^late  to  the  last,  and,  by  attaching 
to  its  palatal  surface  a  small  India-rubber  ring,  draw  the  [)romi- 
uent  teeth  backwards  into  position :  the  plate  must  of  course  be 
cut  away  at  the  backs  of  such  teeth  to  enable  it  to  do  so.  It 
must  be  borne  in  mind  that  teeth  so  moved  have  not,  as  in  the 
underhung  cases,  a  barrier  to  prevent  their  return  to  the  ab- 
normal positions — there  will  be  nothing  but  the  elasticity  of 
tiie  lip;  the  plate  must  therefore  be  worn  much  longer,  namely, 
until  the  vacancy  in  the  anterior  portions  of  the  alveoli  caused 
by  the  movements  of  the  teeth  have  become  tilled  up  with  bony 
material.  In  the  movement  of  teeth  by  mechanical  means,  it  is 
important  to  bear  in  mind  the  fact  that  the  earlier  it  is  attempted 
after  their  eruption  the  more  easily  it  will  be  otlected,as  at  that 
time  the  teeth  are  not  closely  surrounded  by  bone  as  they  become 
afterwards. 

A  detained  root  or  tooth  may  also  have  the  effect  of  causing 
an  erupting  permanent  tooth  to  become  twisted  on  its  long  axis, 
80  that  its  inner  and  outer  edges  become  placed  in  the  antero- 
posterior direction,  and  its  cutting  or  masticating  edge  at  right 
angles  to  the  opjiosing  tooth  of  the  opposite  jaw.  When  this 
condition  has  occurred  in  an  upper  central  or  lateral  incisor  or 
cusj»idatus,  it  has  been  recommended  that  where  there  is  a  suffi- 
ciency of  room  the  case  shouhl  be  treated  by  what  nnxy  be  termed 
immediate  torsion,  i.  «.,  by  grasping  the  tooth  near  its  neck  with 
a  iiair  of  forceps,  guarded  witli  tliin  leather  or  other  substance 


IRREGULARITIES    IN    PERMANENT    TEETH. 


73 


to  prevent  injury  and  give  firmness,  and  then  steadily  but  forci- 
blv  rotating  it  into  position.  Against  such  practice  when  lirst 
advocated  we  urged  a  protest,  on  the  ground  of  injury  likely  to 
occur  to  vessels  and  nerves  upon  which  the  vitality  of  a  tooth 


Fi<r.  87. 


Plate  adapted  for  drawing  inwards  front  teeth  of  the  upper  jaw.  The  right  central  incisor  has 
been  erupted  anterior  to  its  temporary  predecessor,  the  root  of  which  is  figured,  and  which  should 
of  course  be  extracted  prior  to  treatment,  which  will  consist  either  in  drawing  the  central  incisor 
back  by  an  elastic  India-rubber  band  or  by  a  band  of  platinum,  which  passes  in  front  of  the  tooth 
and  which  by  means  of  nuts  and  screws  at  the  side  of  the  plate  can  be  gradually  tightened  by 
turning  the  nuts.  The  latter  arrangement  is  best  suited  in  the  case  of  having  to  act  on  several 
teeth  at  once. 


Fio;.  38. 


depends,  and  the  results  of  that  operation  which  liave  come 
under  our  notice  have  verified  our  predictions.  We  recently 
had  to  remove  a  necrosed  upper  right  lateral  tooth  which  had 
been  thus  rotated  ;  yet  the  eminence  of  the  operator  was  a 
gaurantee  that  the  operation  had  been 
most  carefully  performed.  The  tooth 
had  never  come  down  to  the  proper 
length,  and  was  very  dark  in  color; 
when  it  was  removed,  it  was  found 
that  the  fang  was,  more  than  half  of 
it,  absorbed.  Such  cases,  then,  we 
should  recommend  to  be  treated  by 
means  of  a  plate,  so  constructed  that 
pressure  may  be  applied  at  each  edge  of  the  offender,  and  in 
this  way  it  will  be  mediately  rotated  in  its  sockets  with  perfect 
safety.  We  have  thus  rotated  a  central  incisor  tooth  nearly  two- 
thirds  of  a  complete  circle. 

[As  elsewhere  remarked,  immediate  torsion  is  frequently  pre- 
ferred, indeed,  is  often  the  only  thing  that  the  patient  will  sub- 
mit to,  so  great  is  the  soreness  resulting  from  the  slower  method, 


Right  central  Incisor  of  the  upper 
jaw  erupted  at  an  angle  to  the  den- 
tal arch  from  want  of  space. 


74     MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

SO  long  kept  up.  Generally  the  performance  of  the  operation,  as 
well  as  most  attempts  at  correction  of  position  by  force,  should 
be  delayed  until  the  formation  and  dentinification  of  the  end  of 
the  root  has  been  fully  completed,  which  may  usually  be  con- 
sidered to  be  within  a  few  months  after  the  tooth  has  been  in 
antagonism  with  those  of  the  other  jaw.  The  tooth  should  be 
firmly  grasped,  and  care  must  be  exercised  to  apply  the  force 
moderately,  slowly  increasing  it  until  the  slight  movement  of 
the  tooth  aftbrds  the  operator's  cultivated  and  delicate  sense 
of  touch  the  warning  necessary  to  be  obeyed  if  the  root  is  not 
straight,  and  therefore  not  adapted  to  immediate  torsion.  This 
knowledge  derived  from  touch  in  extraction  of  teeth,  in  the  use 
of  probes,  and  in  the  excavation  of  teeth,  is  naturally  constantly 
cultivated  in  the  dentist.  Precaution  must  be  o!)served  that 
the  tooth  is  not  pushed  upward  in  its  socket,  and  the  apex  of 
the  root  in  that  way  brought  to  bear  upon  the  bone;  or,  on  tlie 
other  hand,  not  to  allow  a  downward  movement,  as  in  extrac- 
tion, on  account  of  the  danger  of  injuring  the  apical  nerve  fila- 
ments or  bloodvessels.  The  subsequent  treatment  is  generally 
simple  enough, — in  the  majority  of  cases  the  tooth  is  best  held 
in  its  new  position  by  its  fellows.  Ligatures  are  dangerous 
because  liable  to  slip  up  around  the  neck  and  cause  additional 
inflammation  of  the  pericemental  tissues. 

The  failures  reported  thus  far  indicate  the  signal  importance 
of  precautions  against  injuries  to  the  tissues  at  the  apex  of  the 
root,  and  particularly  if  the  apices  are  not  completely  formed. 

It  is  of  course  necessary  that  there  should  be  room  to  admit 
of  the  turning  of  the  tooth  crown  between  its  fellows,  and  to 
gain  this,  wedging  will  sometimes  be  necessary.  Very  thin 
rubber  dam,  well  lathered  with  soap,  will  act  as  a  guard  if 
passed  between  the  impinging  points  of  the  adjacent  teeth  and 
the  one  to  be  moved  ;  but  care  must  be  taken  to  interpose  no- 
thing that  will  interfere  with  the  observation  of  the  movement, 
which  must  be  slow  and  deliherate. 

After-treatment  is  rarely  required,  but  maybe  antiphlogistic. 
To  keep  down  inflammation,  a  small  pledget  of  cotton,  saturated 
with  lead-water  and  laudanum,  may  be  laid  between  the  lip  and 
gum  over  the  root,  and  in  extreme  cases  systemic  treatment,  as 
a  saline  cathartic,  might  be  indicated. 

It  has  been  with  many  in  this  country  the  [»ractice  to  correct 


IRREGULARITIES    IN    PERMANENT    TEETH. 


75 


by  ligatures  most  cases  of  irregularity,  as  recommended  by  Prof. 
J.  F.  Flagg.     For  this  purpose  the  art  of  tying  several  knots 


FiK.  39. 


FU'.  40. 


The  half  hitch. 


The  square  knot. 


must  be  learned:  1st,  the  half  hitch  ;  2d,  the  square  knot  ;  3d, 
the  surgeon's  knot;  4th,  the  clove  hitch. 


Fiff.  41. 


Fi£c.  43. 


The  surgeon's  knot. 


The  clove  hitch. 


Suppose  it  be  desired  to  draw  a  single  tooth  out  to  a  position 
in  the  arcii  corresponding  to  its  fellows,  as  the  left  lateral  in 
Fig.  43:  Take  a  piece  of  highly  elastic  rubber,  conveniently  a 


Fis:.  43. 


Fiff.  44. 


O    O    o 


Rings  cut  from  rubber  tubing 


Drawing  a  tooth  forward  into  the  arch 
by  an  elastic  ligature.  (After  a  plaster 
cast.) 


ring  cut  from  a  French  rubber  tubing  such  as  is  used  for  sepa- 
rating teeth.  Fig.  44,  say  from  ith  to  ith  inch  in  diameter,  tie 
to  this  by  a  square  knot  a  piece  of  strong  sewing-machine  shoe- 


76  MANUAL    OF    DENTAL    SURGERY     AND    PATHOLOGY. 

thread,  leavin^^  the  end  six  or  eight  inches  long  from  the  ring; 
by  these  ends  tie  the  rubber  tightly  against  the  first  bicus- 
pid or  molar  on  that  side.  Tie  a  similar  piece  of  thread  and 
rubber  to  a  bicuspid  or  molar  of  the  other  side,  and  pass  one 
end  of  another  thread  through  the  rubber  ring  stretching  in 
front  of  all  the  oral  teeth,  except  the  one  to  be  drawn  into 
place,  behind  which  it  will  pass.  Tie  fast  by  a  surgeon's  knot, 
and  thus  keep  up  steady  tension. 

If  the  teeth  antagonize  so  as  to  prevent  the  tooth  from  pass- 
ing front  to  its  position,  one  or  more  of  the  lower  teeth  in  the 
vicinity  may  be  capped  with  gutta  percha,  silver,  or  gold,  to 
prevent  the  occlusion  and  interference. 

To  make  the  caps,  take  a  small  piece  of  gutta-percha  (the 
pink  trial  plate  will  do  well),  warming  it  slightly  and  pressing 
over  and  shaping  it  on  the  teeth  designed  to  be  capped  ;  let  the 
jaws  be  closed  upon  it  until  the\'  are  only  sufficiently  wide  apart 
for  the  above  pur[)Ose,  and  then  trim  to  a  shape  that  will  inter- 
fere as  little  as  possible  with  the  patient's  lips,  tongue,  and 
cheek  ;  remove  the  gutta-percha  while  yet  warm ;  squeeze  slightly 
together  the  edges  that  grasp  the  necks  of  the  teeth,  and  chill 
it  quickl}'  in  cold  water.  The  cap  will  then  require  to  be  sprung 
over  the  teeth  to  which  it  is  adapted,  and  will  retain  itself  in 
position.     This  method  was  taught  by  Prof.  J.  F.  Flagg. 

The  late  Prof.  McQuillen  recommended  a  thin  piece  of  plate 
(silver  or  gold)  to  be  cut  and  folded  as  in  the  diagrams,  after  the 
manner  in  which  paper  boxes  are  made.  Prof.  McQuillen  also 
recommended  for  correction  of  this  kind  of  irregularity  a  strip  of 
gold  clasp  plate,  as  in  the  diagram,  the  two  ends  secured  to  the 

Fig.  45.  Fig.  40. 


Prof.  McQuillen'g  cap  to  prevent  occlusion  of  tlie  Prof.  McQuillon's  bar  for  drawing  tootli  for- 

teeth.     (From  the  Dental  Cosmos.)  ward.     (From  the  Dental  Cosmos.) 

bicuspid  or  molar  on  either  side,  and  rubber  ligatures  or  rings 
thrown  over  the  dovetail-shaped  parts  and  the  tooth  or  teeth 
that  it  is  desired  to  draw  forward. 

In  most  cases  it  is  best  to  attem[)t  the  moving  of  but  one  or 


IRREGULARITIES    IN    PERMANENT    TEETH. 


77 


at  most  two  at  a  time,  both  on  account  of  the  greater  soreness 
and  the  danger  of  displacing  the  teeth  used  as  fulcrums. 


Fiff.  47. 


Fie:.  48. 


A  method  of  diawini:  a  tooth  into  rosition  by  an  elastic  ligature.     (From  the  Dental  Cosmos.) 

If  the  same  tooth  were  pLaeed  outside  of  the  arch,  a  rubber 
ring  might  be  tied  to  the  pahital  face  of  each  of  the  first  bicus- 
jiids  or  molars,  and  a  strand  of  the  ligature  stuft" carried  through 
both  rings  and  in  front  of  the  tooth,  whicli  upon  tying  would 
stretch  the  rubber  and  cause  it  to  draw  the  tooth  inward. 

If  a  tooth  were  to  be  twisted  upon  its  axis.  Prof.  Flagg  recom- 
mended the  clove  hitch,  over  which  the  ends  of  the  ligature  are 
passed  and  then  tied  tightly  with  a  sur- 
geon's knot,  to  grasp  it  so  fii-mly  as  to  pre- 
vent its  slipping  on  the  tooth,  and  enable 
the  ends  to  be  carried  to  a  rubber  ring  tied 
as  before  U[)on  a  neighbor,  and  b}'  its  elasti- 
city keep  up  a  constant  torsion  pull.  Or  both 
ends  may  be  wound  around  the  tooth  in  the 
direction  that  it  is  to  be  turned,  and  one  of  these  carried  to  a  rub- 
ber fastened  on  the  right  side,  and  the  other  to  a  similar  rubber 
on  the  left  side,  of  the  mouth,  thus  doubling  the  power.  Some- 
times plates  are  used  with  advantage,  as  in  the  accompanying 
cuts. 

Should  it  be  desired  to  draw  the  lower  oral  teeth  so  as  to 
close  behind  the  upper,  the  elastic  rings  should  be  attached 
to  the  inside  of  the  bicuspids  or  molars,  and  b}-  a  ligature  as 


Prof.  Flag-g's  method  of  tying 
litfature  for  torsion. 


(8     MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

sliown  in  Fig.  49,  concentrate  their  pressure  upon  one  tooth 
at  a  time  until  thej  are  brought  in  about  one-sixteenth  to  one- 
eighth  of  an  inch  behind  the  point  desired.  The  rubber  rino-s 
may  be  replaced  by  simple  ligatures  at  any  time  to  hold  the 

Fi£r.  49. 


A  ca~o  r.f  torsion   ami   retracfou  of  central  incisors  by  a  jilatc  with   iiins  and  elastic  llgaturos. 
(From  the  Dental  Cosmos.) 

teeth  firmly  in  the  position  gained,  or  to  give  a  resjiite  from 
the  pressure  which  it  sometimes  becomes  advisaljle  to  relieve. 

Prof.  Guilford,  to  avoid  the  pain  caused  by  the  slipping  up 
of  the  ligatures  and  wounding  of  the  gums,  has  devised  the 
attachment  of  thin  gold  clasps  to  the  teeth,  which  may  be  held 
in  position  by  a  cement,  as  the  oxy-phosphate,  and  the  tying  of 
the  ligatures  to  these. 

The  same  operator  has  also  devised  a  simple  appliance  for 
producing  torsion,  which  I  give  in  his  own  words:' — 


'  From  llic  Dental  Office  and  Laboratory,  Oct.  1878. 


IRREGULARITIES    IN    PERMANENT    TEETH.  79 

"It  is  made  entirely  of  gold,  and   is  constructed  as  follows: 
A  model  of  the  teeth   being  secured  in  plaster,  a  ])iece  of  gold 
backing  was  cut,  an   eighth   of  an   inch   wide,  and 
long  enough   to  extend   along  the  palatine  surfaceti  '=_/   ' 

of  the  two  centrals,  and  a  little  beyond  at  each  end.     ^^J^ 
After  rounding  the  edges  and  corners,  this  stri[)  was 
bent  to  conform  as  closely  as  possible  to  the  lingual  surfaces  of 
these  teeth,  and  the  ends  turned  forward  so  as  to  slightly  clasp 
the  disto-palatine  ano;les  as  shown  in  F\o-,  51. 

"  Two  strips  were  then  cut  from  upper-plate  scrap,  a  little  nar- 
rower than  the  first  piece,  and   bent  in  the  form  of  b  and  c 
respectively.     These  were  made  long  enough  to  be  bent  slightly 
over  the  labial  surface  of  the  teeth,  extending 
along  tlie  mesial  surface  to  the  palatine,  and  ^'^°-  ^^^• 

then  along  this  surface  almost   to   the   distal     c _)  f".         5 

angle.     After  being  properly  shaped  according  ^   \ 

to  the  model,  they  were  clamped  together  and       ^'^P^'^ — ^ 

soldered  jdons;  tlieir  contis^uous  surfaces.     This  'i'' 

...  ^ 

part  was  then  placed  in  position  on  the  model, 

and  the  long  ends  bent  to  conform  to  the  inner  surface  of  a, 

held  temporarily  in  position.     The  parts  were  then  removed, 

and  the  part  h-c  was  clamj)ed  and  soldered  to  a  in  its  proper 

position.     The  only  thing  then  to  be  done  to  complete  the  piece 

was  to  reduce  the  thickness  of  the  part  b-c,  by  filing,  where  it 

passed   between  the  teeth,  and  polish  the  appliance.      Before 

applying,  a  piece  of  thin  ruldjer  was  placed  between  the  natural 

teeth  for  a  day,  to  separate  them  slightly  and  admit  of  the 

introduction  of  the  appliance.     When  properly  constructed,  the 

labial  part  of  the  apparatus  will  rest  against  the  teeth  just  at, 

or  slightly  al»ove,  the  most  prominent  part  of  their  convexity; 

while  the  lingual  portion  will  be  near  the  gum,  but  not  quite 

touching  it,  and  the  slightly-curved  ends  of  this  part  will  catch 

just  above  the  little  nodule  usually  found  on  the  disto-palatine 

angle  near  the  gum.     When  thus  made  and  placed,  the  piece 

cannot  become  displaced  by  the  action  of  the  lip  or  tongue. 

"  The  whole  process  of  eftectiug  the  double-rotation  of  these 

teeth  with  this  appliance,  is  to  see  the  patient  every  day,  each 

time  bend   the   long  palatine  arms  slightly  toward   the  short 

labial  ones,  and  spring  it  back  into  position  on  the  teeth.     The 

elasticity  of  the  gold,  increased  by  the  stiffness  the  solder  has 


80 


MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 


given  to  it,  will  do  the  work.  This  daily  bending  should  be 
continued  until  the  teeth  are  rotated  into  tlieir  proper  position. 
This  can  usually  be  effected  in  about  ten  days. 

"  B}'  this  method  the  use  of  all  rubber  or  silk  ligatures,  so 
irritating  to  the  gum,  and  so  painful  in  their  application,  is  dis- 
pensed with.  There  is  nothing  unsightly  about  it,  as  the  only 
j)art  exposed  to  view  is  the  very  small  portion  on  the  labial 
surface;  nor  is  there  enough  of  the  whole  appliance  to  irritate 
either  the  lip  or  tongue,  or  in  the  least  annoy  the  patient.  It 
dispenses,  also,  with  the  wearing  of  a  plate  on  the  roof  of  the 
mouth,  a  very  great  desideratum  in  the  matter  of  distinct  enun- 
ciation, for  our  patients  at  the  time  of  these  operations  are 
always  in  their  school-days. 

"The  ease  with  which  it  can  be  constructed,  requiring  only 
from  half  an  hour  to  an  hour,  and  the  rapidity  with  which  it 

F\s:.  52. 


can  he  removed,  bent  and  replaced  each  dny,  are  also  among  its 
great  recommendations.  To  guard  against  its  accidental  loosen- 
ing and  loss,  especially  at  night,  it  has  been  my  custom  to  tie  a 
thread  around  one  of  the  centrals  and  under  the  front  bar. 

"One  of  three  cases  treated  in  this  way  during  the  summer 
of  1874,  the  i)atient  being  seen  every  day,  was  easily  corrected 
in  ten  days'  time.  Fig.  52  is  a  representation  of  her  teeth 
before  treatment,  and  Fig.  53  afterward. 

"The  same  appliance  can  be  used  witii  equal  eft'ectivencss  in 
cases  (not  so  frequently  met  with)  just  the  oi)posite  of  those  I 
have  been  describing — that  is,  where  the  distal  surfaces  are  in- 


IRREQULARITfES    IN    PERMANENT    TEETH. 


81 


clined   outward,  and   the  mesial   inward.      In   these  eases  the 
whole  operation  has,  of  course,  to  be  reversed.     The  long  arm 

Fig.  53. 


or  band  goes  on  to  the  labial  surface,  and  the  short  one  to  the 
palatine,  and  the  ends  of  the  long  arm  have  to  be  so  bent  as  to 
throw  the  distal  angles  inward.  I  have  just  finished  a  case  of 
this  kind,  shown  in  Fig.  54,  with  perfect  satisfaction,  using  no 
other  appliance  than  the  one  above  described. 


Fig.  54. 


'^'^^'^^"mmiilBiiiM 


"  The  same  appliance,  slightly  modified,  I  have  also  used  for 
rotating  but  one  of  the  teeth,  where  the  other  is  already  in 
position.     In  this  case  the  half  of  the  appliance  touching  the 
6 


82  MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

tooth  not  to  be  moved  is  made  to  fit  it  nicely,  both  on  the  pala- 
tine surface  and  on  the  labial ;  but  the  other  half  must  be  made 
long  enough  at  the  part  that  goes  between  the  teeth  to  grasp 
the  protruding  tooth  around  its  mesial  surface,  and  the  long  arm 
on  the  palatine  surface  must  be  made  a  little  longer,  to  accom- 
modate the  whole  width  of  the  tooth  when  it  comes  into  posi- 
tion. The  rotation  is  then  usually  done  by  simply  bending  from 
day  to  day  the  short  arm  on  the  labial  surface. 

"A  retaining  plate  for  the  first  mentioned  class  of  cases  is 
best  made  of  rubber,  having  imbedded  in  it  the  palatine  portion 
of  the  appliance — while  one  for  the  class  illustrated  by  Fig.  54, 
consists  of  a  rubber  plate  with  a  light  gold  wire  imbedded, 
extendino;  alons;  the  middle  of  the  labial  surfaces  of  the  centrals 
and  laterals,  and  so  constructed  as  to  certainly  touch  the  angles 
of  the  teeth  that  before  protruded. 

"As  this  simple  appliance  has  proved  so  eflficient  and  satis- 
factory in  my  hands,  and  in  the  hands  of  some  friends  who  have 
tried  it,  I  have  been  induced  to  give  it  to  the  profession  in  this 
public  way,  hoping  that  it  may  serve  to  lighten  the  labors  of 
fellow-dentists,  and  lessen  the  discomforts  of  their  patients." 

The  permanent  superior  oral  teeth,  as  a  rule,  should  erupt  on 
the  labial  side  of  the  deciduous  teeth,  and  those  of  the  inferior 
jaw  should  present  upon  the  lingual  side.  Any  deviation  from 
this  will  indicate  the  necessity  for  the  services  of  the  dentist 
and  the  extractioji  of  the  milk  tooth  or  teeth  corresponding  to 
those  erui>ting. 

Where  lateral  crowding  is  threatened,  it  is  rarely  desirable  to 
remove  the  deciduous  teeth  on  either  side  of  tiie  erupting  per- 
manent one.  It  seems  probable  that  the  wedging  into  position 
tends  to  enlarge  the  arch. 

It  not  infrequently  occurs  that  from  want  of  room  the  canines 
erupt  outside  of  the  arch,  and  the  bicuspids  are  so  far  into 
position  as  to  interlock  their  cusps  with  those  of  the  o{)posite 
jaw  when  occluded.  Rather  than  attempt  to  jump  the  bicus- 
pid cusps  over  their  antagonists,  it  will  generally  be  best  to  ex- 
tract the  first  bicuspids  and  allow  the  canines  to  fall  back  into 
the  spaces  vacated  Ijy  the  extraction.  This  avoids  the  irritation 
of  the  tissues  and  the  initiation  of  abnormal  blood  currents, 
which  might  ultimately  induce  hypertrophy,  or  otlier  trouble, 
about  the  roots. 


IRREGULARITrES    IN    PERMANENT    TEETH.  83 

It  has  lono;  been  a  rule  with  dentists  to  preserve  the  decidu- 
ous canines, for  their  position  in  the  arch  is  important;  they  act 
somewhat  like  keystones,  tending  to  preserve  the  regularity 
and  beauty  of  the  curve  described  by  the  teeth  of  the  perma- 
nent denture.] 

Another  cause  of  irregularity  of  the  permanent  teeth  in  posi- 
tion, is  stated  to  be  the  habit  of  thumb  and  tongue  sucking. 
It  is  probably,  in  such  cases,  due  to  some  peculiarity  in  the 
manner  in  which  the  habit  is  practised  ;  for  we  may  have,  as  in 
the  family  of  the  writer,  a  member  who  was  subject  to  a  con- 
siderable projection  of  both  temporary  and  permanent  upper 
incisors,  j^et  who  never  had  the  habit:  whilst  the  next  in  age, 
a  most  inveterate  thumb-sucker,  has  the  most  perfectly  formed 
arch  of  a  large  family.  On  the  other  hand,  we  have  under 
observation  a  child  about  five  years  of  age,  who  invariably  sucks 
the  right  thumb,  and  in  whom  not  only  the  front  teeth,  but  the 
alveolar  process  of  that  side,  are  abnormally  prominent.  The 
treatment,  of  course,  will  be  the  prevention  of  the  habit,  and  the 
wearing  of  a  coarse  worsted  glove  will  generally  effect  the 
object:  if  not,  the  continual  a]»plication  of  aloes  to  the  favorite 
thumb  will  probably  do  so.  The  treatment  of  irregularities 
which  are  the  result  of  tumors  will  of  course  consist  in  attention 
to  the  latter. 

Irregularity  in  position  of  the  teeth,  the  result  of  fracture  of 
the  jaw,  although  coming  more  under  the  province  of  the  general 
than  that  of  the  dental  surgeon,  may,  however,  in  the  majority 

Fiff.  55. 


Case  of  fracture  of  the  lower  jaw,  transversely  through  the  hody,  treated  by  means  of  a  metallic 
cap,  which  fits  tightly  over  teeth  on  each  side  of  the  fracture,  and  thus  holds  tho  fragments  in  firm 
apposition. 

of  cases  be  treated  most  successfully  by  the  means  and  appliances 
which  are  best  known  to  the  latter,  and  especially  in  cases  where 
many  of  tlie  teeth  are  not  wanting.  To  put  up  a  fracture  of 
the  lower  jaw,  where  much  distortion  exists,  with  a  well-adapted 


84 


MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 


gutta-percha  splint,  moulded  to  the  chin,  and  retained  by  a 
four-tailed  bandaoje,  appears  to  us  about  as  good  a  means  for 
perpetuating  a  deformity  as  would  be  the  jipplication  of  a 
plaster-of-Paris  bandage  to  an  unreduced  fracture  in  a  limb. 
A  simple  form  of  treatment  of  a  fracture  in  either  jaw  will 


Fio-.  56. 


Model  taken  from  a  vertical  fnicturo  of  the  lower  jaw  between  the  left  cuspidatus  and  first 
bicuspid.  The  dotted  line,  which  indicates  the  fracture,  is  the  line  to  be  sawn  through  in  order 
to  bring  the  model  into  the  normal  position  of  the  jaw. 

consist  in  constructing  a  plate  of  metal  that  will  cap  and 
securely  hold  several  of  the  teeth  on  both  sides  of  the  injury. 
To  effect  this,  wax  or  plaster  impressions  are  taken  of  both  jaws, 
the  fractured  one  in  its  abnormal  position  ;  from  these  plaster 


Fig.  57. 


The  engraving  nhows  how,  by  means  of  a  cast  of  the  tipper  jaw,  the  two  fragments  of  Fig.  r>6  can 
be  placed  in  precisely  the  normal  position  of  the  lower  jaw  before  the  fracture  occurred. 

models  are  obtained,  and  that  representing  the  injured  jaw 
sawn  through  in  tlic  line  of  the  fracture.  The  two  divided 
portions  arc  now  fitted  by  the  crowns  of  the  teeth  to  their 
corresponding  places  with  the  crowns  of  the  teeth  in  the  model 
of  the  uninjured  jaw,  and  the  relative  positions  of  both — the 


IRREGULARITIES    IN    PERMANENT    TEETH.  85 

bite  or  articulation — as  they  existed  before  the  injury  are  tljus 
obtained,  and  the  divided  portions  are  again  united  by  plaster. 
To  the  model  representing  the  fractured  jaw  a  metal  or  vul- 
canite plate  is  constructed,  capping  three,  four,  or  more  teeth 
on  both  sides  of  the  injury  as  the  case  may  admit.  To  obtain  a 
good  hold,  the  plate  may  be  lined  with  gutta-percha,  which,  at 
the  time  of  its  application,  is  made  warm  and  retained  until 
cold ;  or  small  screws  may,  as  adopted  by  Barrett,  pass  through 
the  sides  of  the  plate  and  between  the  teeth  at  their  necks.  If, 
however,  a  little  care  be  taken  in  the  construction  of  a  metal 
plate,  so  that  it  fits  accurately  and  firmly  at  the  necks  of  the 
teeth,  the  gutta-percha  or  screws  may  be  dispensed  with. 
Small  holes  are  sometimes  drilled  in  the  plates,  to  admit  of 
syringing  and  the  egress  of  discharge,  but  in  a  plate  that  merely 
caps  the  teeth  these  will  not  be  required.     A  double  interdental 

Fio;.  58. 


Gunning's  interdental  splint  for  fractures  of  either  jaw,  and  in  which  the  sound  jaw  assists  in 
retaining  in  position  the  fragments  of  the  fractured  one 

splint  has  been  devised  by  Gunning,  and  is  especially  adapted 
to  cases  in  which  more  than  one  vertical  fracture  through  the 
body  of  the  bone  exists.  It  is  best  constructed  of  vulcanite, .and 
consists  of  an  interdental  splint  for  each  jaw,  constructed  in 
one  piece.  By  it,  the  two  jaws  act  upon  each  other,  the  sound 
one  assisting  in  holding  the  injured  one  in  position.  The  jaws 
are  kept  a  short  distance  apart,  and  an  opening  between  the  two 
splints  in  front  of  the  mouth  admits  of  the  introduction  of 
fluid  food  without  movement  of  the  jaws.  The  plates  may  be 
retained  by  the  screws,  but  with  adults  this  is  not  as  a  rule 
necessary,  as  a  bandage  round  the  head  will  keep  the  two  jaws 
together. 

But  of  all  appliances  devised  to  this  end,  and  especially  for 
fractures  of  the  lower  jaw,  the  splint  of  Hammond  certainly,  in 


86 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY 


our  opinion,  appears  the  most  efficacious.  It  consists  of  a  stout 
piece  of  iron  wire,  bent  so  as  to  include  the  whole  dental  arch 
on  both  sides  of  it,  and  soldered  at  its  terminations.  When 
applied  to  the  dental  arch,  it  should  just  rest  upon  the  gum  on 


Fig.  59. 


Hammond's  splint  in  situ. 


either  side  at  the  level  of  the  necks  of  the  teeth.  When  so 
placed,  it  is  firmly  secured  to  the  jaw  by  passing  fine  silver  or 
iron  binding  wire  between  the  teeth  at  their  necks,  and  attach- 
ing it  to,  and  twisting  it  tightly  upon,  its  inner  and  outer 
portions.  It  is  a  somewhat  tedious  and  unpleasant  process, 
but  such  labor  is  well  repaid  when,  as  in  a  case  recently  treated 
at  St.  Bartholomew's  Hospital  by  our  esteemed  colleague, 
I.  Lyons,  the  patient  within  half  an  hour  of  its  application  had 
eaten  a  mutton-chop  and  smoked  a  pipe  with  much  satisfaction. 
In  the  case  of  edentulous  jaws,  vulcanite  splints  may  be  adapted, 
but  even  if  lined  with  soft  rubber,  a  material  about  as  hard  as 
leather,  their  pressure  on  the  soft  mucous  membrane  can  be  but 
ill  tolerated,  and  especially  when  in  the  lower  jaw  they  are 
secured  to  the  chin,  by  connecting  the  splint  with  a  gutta- 
percha cap  fitted  over  the  latter. 

[As  a  temporary  splint  for  fractures  of  the  jaws,  two  or  three 


IRREGULARITIES    IN     PERMANENT    TEETH.  87 

sizes  of  silver,  or  gold,  plates  struck  up  like  lower  impression 
cups,  without  handles,  might  he  kept  on  hand.  Cut  these  open 
at  the  incisors  to  attbrd  feeding  space,  and  drill  holes  to  pass 
wire  for  binding  them  together;  fill  with  gutta-percha  rendered 
plastic  by  heat.  They  should  tiien  be  pressed  upon  the  teeth, 
after  the  fractures  are  reduced,  and  wired  together  to  hold  the 
jaws  and  the  parts  in  jiosition,  until  more  elaborate  splints  are 
made,  if  necessary.  This  splint,  suggested  and  used  by  the 
writer,  has  been  found  sufficient,  and  actual  practice  on  frac- 
tured jaws  has  demonstrated  that  often  no  other  was  required.] 


88  MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 


CHAPTER  IV. 

IRREGULARITIES  IN  THE  PERMANENT  TEETH  {continued). 

II.  Congenital  and  Unavoidable. — The  irregularities  which 
we  have  classed  under  this  head  are  the  result  of  an  undue  rela- 
tionship between  the  teeth  and  the  maxillse,  i.  e.,  w^here  the  lat- 
ter are  developed  in  excess  as  regards  the  former,  and  vice  versa. 
The  former  alternative,  by  far  the  less  common  in  the  present 
day,  may  result  in  the  teeth  having  abnormal  interspaces,  and 
most  commonly  between  the  two  central  incisors  of  the  upper 
jaw;  or,  as  is  not  unfrequently  the  case,  a  bicuspid  may  have 
been  erupted  so  that  its  lateral  surfaces  become  placed  in  the 
reverse  position,  viz.,  externally  and  internally.  That,  how- 
ever, which  is  certainly  more  common  in  the  present  day  is 
where  the  reverse  of  the  above  prevails,  and  the  maxillse, 
especially  their  alveolar  portions,  are  not  developed  commen- 
surately  with  the  teeth.  That  such  condition  prevails  to  a 
greater  extent  now  than  some  generations  since,  and  is  apparently 
on  the  increase,  is,  we  believe,  the  unvarying  opinion  of  practi- 
tioners who  have  Inid  the  opportunity  of  having  under  observa- 
tion the  mouths  of  three  and  often  four  generations  of  the  same 
families;  and  such  opinions  are  confirmed  by  the  comparison 
of  old  skulls  with  those  of  persons  of  the  present  age.  The 
examination  of  some  200  skulls  in  the  crypt  of  the  church  at 
Hythe,  when  measured  from  the  anterior  fang  of  one  fi.rst  upper 
molar  near  its  neck  to  tlie  same  jiortion  of  the  corresponding 
tooth  upon  the  opposite  side  of  the  jaw,  gave — greatest  width, 
2|  inches;  least  width,  2|-  inches;  average  width,  21-  inches: 
which,  com})ared  with  the  average  in  recent  skulls,  gives  an 
excess  in  favor  of  the  former,  whilst  the  teeth  appeared  to  be 
about  the  same  average  size  formerly  as  now:  "In  no  single 
instance  was  there  anything  seen  approaching  to  that  which 
under  the  term  'contracted  arch'  so  commonly  exists  in  the 
present  day  ;  they  all  presented  an  architecture  characteristic  of 


IRREGULARITIES    IN    PERMANENT    TEETH. 


89 


the  church  that  contained  them  ;  tlie  Gothic  architecture  of  a 
more  retined  period  in  them  also  had  not  as  yet  made  its  ap- 
pearance."^ But  what  was  still  more  conspicuous  in  these  old 
skulls  was  the  inclination  outwards  of  the  teeth  and  alveolar 


Fitr.  CO. 


t  f 

Well-developed  upper  jaw  ia  a  youth  aged  about  twelve  years. 

processes,  of  especially  the  upper  jaw,  which  gave  a  more  promi- 
nent and  consequently  more  capacious  dental  arch  ;  so  much  so 
that  in  many  the  third  molars  occupied  the  position  which  we 
now  see  occupied  by  the  first  molars. 

There  can  be  no  doubt  but  that  the  chief  cause  for  this 
departure  is  that  assigned  by  Darwin^  and  Wallace,  viz.,  those 
altered  conditions  in  the  food  of  man,  with  tlie  less  necessity 
for  exercising  his  teeth  and  jaws,  in  an  age  of  advanced  civiliza- 
tion. Together  with  this  explanation  must  also  be  considered 
the  effect  of  a  sexual  selection  or  breed ing-in,''  which  tends  per- 
petually to  continue,  and  further  develo[»  an  ai)proved  type. 

[Tonsillitis^  has  likewise  been  pointed  out  as  a  cause  of  the 
contraction  of  the  arches  at  the  bicuspids.  The  labored  breath- 
ing, from  the  filling  up  of  the  fauces  by  these  swollen  glands, 


'  "Remarks  upon  the  Collection  of  Skulls  in  the  Crypt  of  Hythe  Church, 
Kent,"  by  Samuel  Cartwright  and  A.  Coleman,  Trans.  Odont.  Soc,  vol.  iv.  p. 
221,  old  series. 

2  The  Descent  of  Man,  by  C.  Darwin. 

*  "  Reflections  on  the  Cause  and  Treatment  of  some  forms  of  Irregularity," 
by  S.  Cartwright,  Trans.  Odont.  Soc,  vol.  iv.  p.  114,  old  series. 

[*  See  p.  11,  "Oral  Deformities,"  by  Norman  W.  Kiugley,  M.D.S.,  D.D.S., 
D.  Appleton  &  Co.,  New  York,  1880.] 


90 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


causes  tlie  cheeks  to  be  compressed  over  the  lateral  parts  of  the 
mouth.] 

One  of  the  characteristics  of  this  type  will  be  a  more  vertical 
development  of  the  teeth  and  alveolar  processes,  as  well  as  a 
greater  prominence  of  forehead  and  chin,  so  that  a  straight  line 
would  fall  nearly  parallel  with  forehead,  base  of  nose,  lips,  and 
chin  ;  whereas  in  an  opposite  type,  such  for  instance  as  is  seen 
in  the  native  of  Australia,  a  line  drawn  parallel  with  forehead, 
base  of  nose,  and  upper  lip  would  form  an  angle  with  one 
parallel  with  lower  lip  and  chin :  in  the  former  arrangement  a 
much  smaller  dental  arch  exists  than  in  the  latter.  As  man- 
kind become  more  refined  in  their  perceptions,  the  forms  most 
indicative  of  refinement  attract  chiefly  their  admiration;  and 
thus  those  the  most  abounding  in  such  characteristics  are  the 
most  likely  to  marry,  and  those  the  most  deficient  in  them  the 
least  likely  to  do  so.  In  other  states  of  society  we  see  the 
reverse  of  this  picture:  the  savage  who  possesses  the  greatest 
physical  strength  (which  is  usually  met  with  in  a  form  most 
wanting  in  those  characteristics  of  which  we  have  just  spoken), 
becomes  usually  a  chief  among  his  people,  and  receives  the 
greatest  marks  of  favor  from  the  females  of  his  tribe;  and, 
where  polygamy  exists,  numbers  more  wives  than  does  he  whose 


Fig.  Gl. 


Imperfectly  developed  upper  jaw  with  irregular  dental  arch.     The  lateral  incisors  are  bitten 
over  by  the  lower  cuspidati. 

tendencies  to  refinement  render  him  an  object  of  contempt,  and 
doubtless  exclude  him  from  female  association.  Thus  the  savage 
races  preserve  for  ages  the  characteristics  of  their  class  with  far 


IRREGULARITIES    IN    TERMANENT    TEETH 


91 


less  deviation  from  them  than  do  those  in  civilized  communi- 
ties ;  there  being  some  limits  to  physical  strength  and  barbarism, 
there  being  none  to  intellectual  and  moral  progress,  save  in 
perfection. 

Whatever  may  be  the  causes  of  a  less  perfect  development 
of  the  maxillae,  and  especially  of  a  more  vertical  position  in  the 
teeth  and  alveoli,  the  result  must  be  obvious,  supposing  the 
teeth  to  be  normal  in  regard  to  size;  viz.,  the  dental  arch  must 
be  irregular,  and  the  most  common  form  which  such  irregularity 
will  assume  will  be  what  our  acquaintance  with  the  positions 
of  the  permanent  teeth  just  prior  to  eruption  would  indicate; 

Fiij.  62. 


Imperfectly  developed  upper  jaw,  aud  where  the  dental  arch  assumes  the  V-shaped  form. 

thus,  the  central  incisors  and  cuspidati  will  be  unduly  prominent 
in  the  dental  arch,  whilst  the  lateral  incisors  will  be  within  the 
dental  arch,  and,  in  the  upper  jaw,  most  probably  bitten  over 
by  the  inferior  cuspidati.  In  another  variety  of  this  form  of 
irregularity  we  have  the  teeth  fairly  in  line,  but  the  incisors, 
especially  of  the  upper  jaw,  are  forced  out,  often  overlapping  at 
the  mesial  line,  and   o-ivino;  to  the  arch  a  V-like  form.^     We 

'  A  praiseworthy  attempt  has  recently  been  made  to  classify  the  various 
forms  of  normal  and  abnormal  maxillfe  that  are  met  with  in  the  present  day, 
by  J.  Okley  Coles,  Trans.  Odont.  Soc,  vol.  xii.  p.  103.  The  subject,  however, 
requires  much  careful  consideration  before  any  classification  of  so  intricate  a 
subject  can  be  adopted. 


92 


MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY 


have  regarded  this  type  as  caused  by  the  eruption  of  the 
cuspidati  before  the  bicuspids,  so  that  they  assume  earlier  a 
position  in  the  arch  at  the  expense  of  the  incisors,  which  are 
driven  forwards,  although  it  may  of  course  result  as  a  conse- 
quence of  the  position  in  which  the  frout  teeth  are  originally 

developed. 

Fiff.  63. 


Imperfectly  and  ill-developed  upper  jaw,  a  case  suitable  for  treatment  by  expansion  of  the 
dental  arch.  C.  S.  Tomes  has  pointed  out  how  this  form  of  irregularity  may  be  explained. 
Thus,  if  the  cornua  of  the  foetal  upper  jaw  are  not  in  the  first  Instance  divergent,  the  subse- 
quently added  portions  which  support  the  three  permanent  molar  teeth  will  form  an  angle  in  the 
bicuspid  region  with  that  previously  existing.  The  matter  is  interesting  from  another  point  of 
view  viz.,  in  regard  to  idiocy.  Langden  Down  has  pointed  out  that,  in  regard  to  congenital 
Idiots,  there  is  almost  always  a  diminution  of  space  between  the  bicuspids,  with  abnormally  high 
vaulting  of  the  palate. 

[This  cannot  be  an  invariable  rule,  for  repeated  examination 
by  Drs.  J.  "W.  White  and  'N.  W.  Kingsley,'  of  the  mouths  of 
the  inmates  of  two  large  institutions  in  this  country,  for  the 
treatment  and  care  of  the  feeble-minded,  has  demonstrated  that 
generally  the  entire  digestive  apparatus  is  almost  abnormally 
developed.  The  jaws  and  teeth  show  a  perfection  of  adaptation 
that  corresponds  with  the  Avell-known  capacity  and  the  alimen- 
tary capability  of  these  unfortunates.] 


['  See  Dental  Cosmos,  April,  1872.  "Tlio  Tlolalion  between  the  Develop- 
ment of  tlie  Mouth  and  Teeth  to  Systemic  and  Mental  Development."  By  Dr. 
J.  W.  White. 

See  Kingsley's  Oral  Deformities,  pp.  30-^7,  where  Drs.  White,  Peirce,  and 
the  writer  are  quoted  as  concurring  in  the  above  view.] 


IRREQULARITIES    IN     PERMANENT    TEETH.  93 

To  such  form  of  irretrularity  two  methods  of  treatment 
present  themselves  by  which  the  teeth  and  maxillaj  may  be 
brought  into  harmonious  relationship,  viz.,  an  expansion  of 
the  alveolar  and  dental  arches,  or  a  diminution  in  the  number 
of  teeth.  The  first  naturally  commends  itself  as  rational  and 
conservative,  especially  where  the  teeth  appear  sound,  and 
should  be  attempted  where  there  is  not  excessive  crowdins;,  and 
particularly  where  one  dental  arch  may  be  perfectly  developed 
whilst  the  other  is  narrow  and  contracted,  and  the  more  so 
should  the  ill-developed  arch  be  the  upper.  The  process  of 
treatment  will  consist,. in  the  upper  jaw,  of  constructing  a  plate 
adapted  to  the  palate  and  internal  surfaces  of  the  teeth  ;  a 
removal  of  a  small  quantity  of  the  plaster  from  the  model  at 
the  necks  of  the  teeth,  and  between  each,  will  generally  insure 
the  firm  attachment  of  the  plate,  and  then,  by  means  of  the 
wedges  previously  described,  the  dental  arch  may  be  in  a  few 
weeks  expanded.  As  the  tendency  to  return  to  the  abnormal 
condition  will  be  considerable,  a  plate  should  be  made,  adapted 
to  the  perfected  arch,  in  order  to  retain  the  teeth  for  several 
months  in  their  altered  position.  The  same  process  in  the 
lower  jaw  is  much  more  difficult  to  carry  out,  and  generally 
not  nearly  so  successful  in  its  results;  fortunately  the  teeth  in 
the  lower  jaw  are  less  seen  than  in  the  u|'per,  and  therefore  its 
treatment  by  expansion  is  seldom  attempted,  unless  to  improve 
mastication  by  a  more  perfect  antagonism  of  the  two  dental 
arches.  If  attempted,  the  process  will  be  best  eifected  by  a 
metallic  plate,  made  to  cap  the  teeth  and  capable  of  being 
expanded  by  a  spring. 

A  more  elegant  but  less  rapid  process  for  expanding  the 
upper  dental  arch  than  that  suggested  above  consists  in  con- 
structing a  plate  as  described — although  it  will  generally  be 
found  necessary  to  cap  the  teeth  in  this  case — dividing  it  into 
two  halves  in  the  line  of  articulation  of  the  palate,  and  then 
vulcanizing  into  each  a  portion  of  a  spring  constructed  of  piano- 
forte wire,  of  the  form  shown  in  Fig.  64.^  The  objection  to 
the  constant  breakage  of  the  spring  from  rusting  may  be  greatly 

'  For  this  ingenious  device,  we  believe,  we  are  indebted  to  Coffin,  of  London, 
and  the  latter  suggestion,  we  are  informed,  to  Kingsley,  of  New  York.  J.  S. 
Turner  tins  his  steel  springs. 


94     MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

overcome  by  inserting  in  the  vulcanite  a  very  small  piece  ot 
zinc  in  contact  with  the  wire.  The  dilatation  of  the  dental 
arch  by  this  apparatus,  though  less  rapid  than  by  wedging,  is 
one  requiring  far  less  constant  attention  on  the  part  of  the 


Fig.  64. 


Fio;.  65. 


Contracted  dental  arch.    CofKii's  method  lor  expanding  the  same  by  means  of  a  divided  plate  and 
spring  formed  of  pianoforte  wire,  the  back  teeth  being  capped. 

practitioner,  and  the  most  suitable  for  patients  who  reside  at  a 
distance  from  him.  In  the  place  of  the  wire  spring  the  jack- 
screw  may  be  employed.  It  is  vulcanized  into  a  plate  of 
similar  construction  to  that  just  described,  or  it  may  be  used 


Fig.  66. 


Fig.  67. 


Til"'  f'XpanH'on  of  a  V-shapod  arch  by  means  of  Codii 
plate.     The  back  teeth  not  capped. 


Tlio  jack-screw,  three  sizes. 


without  any  plate  at  all,  viz.,  by  attaching  its  extremities  against 
the  palatal  surfaces  of  two  0[>p08ite  teeth.  By  inserting  a  small 
])in  into  the  central  portion  and  turning  it  in  one  direction  the 
jack  becomes  elongated,  and  tiiusthe  teeth  are  pressed  outwards 


IRKEGULARITIES    IN    PERMANENT    TEETH. 


95 


ill  the  dental  arch.  There  is  probably  no  appliance  to  equal  it 
in  the  rapidity  with  which  it  effects  its  object,  and  it  is  readily 
under  control  of  the  patient  or  the  patient's  guardians.  But  in 
the  treatment  of  these  cases  our  attention  must  not  be  exclu- 
sively restricted  to  the  condition  of  the  dental  arches;  these 
may  be  brought  into  the  most  perfect  symmetry,  and  yet  the 
result  may  be  anything  but  gratifying;  and  this  is  a  matter 
•which,  we  think,  has  not  received  its  due  share  of  attention  at 
the  hands  of  the  dental  practitioner.  Our  views  on  the  subject 
can  perhaps  be  best  explained  by  narrating  the  history  of  a 
very  instructive  case.  About  the  period  when  tiie  writer 
entered  upon  practice,  a  great  deal  was  written  and  said  on  the 
unjustifiable  procedure  of  removing  sound  teeth  for  the  purpose 
of  regulating  the  dental  arch,  and  expansion  of  the  arch  to 
efiect  that  jturpose  was  stated  to  be,  under  almost  every 
condition,  the  correct  and  legitimate  treatment.  Adopting  the 
views  of  his  seniors,  the  writer  had  the  opportunity  of  putting 
them  into  practice  in  the  case  of  a  young  lady  of  prepossessing 
appearance,  niuch  marred,  however,  by  the  irregularity  of  her 
teeth,  which  presented  the  type  tirst  described  ;  thus,  as  shown 
in  Fig.  61,  the  upper  centrals  and  cuspidati  were  unduly  prom- 
inent, whilst  the  lateral  incisors  were  bitten  over  by  the  cus- 
pidati of  the  lower  jaw.     In  consequence  of  this  arrangement, 


Fio;.  G8. 


The  same  case  as  Fig.  61  after  troatmoiU  by  expansioa. 

the  chin  appeared  elongated  and  unduly  prominent,  partially 
underhung.  The  result  of  the  treatment  was  an  undoubted 
improvement,  the   upper  front  teeth  were  brought  into  perfect 


96  MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

regularity,  the  face  shortened,  and  the  chin  no  longer  prominent. 
In  a  dental  point  of  view  the  result  might  have  been  considered 
perfect,  but  not  so  in  a  facial  point  of  view,  as  the  mouth  had 
been  rendered  undulj'  large  in  proportion  to  the  other  features, 
giving  it  somewhat  of  a  plebeian  aspect.  After  a  year  or  two, 
the  lower  first  molars  became  carious  and  were  removed,  as 
were  also  the  two  upper  first  bicuspids  :  the  effect  was,  that 
the  dental  arches  became  reduced  in  size,  and  the  mouth  assumed 
harmony  with  respect  to  the  other  features.  Such,  then,  will 
be  found,  in  a  large  number  of  cases  of  irregularity  by  crowding, 
to  be  the  proper  treatment,  viz.,  lessening  the  number  of  teeth, 
which,  it  has  already  been  stated,  are  in  the  present  day  so 
often  found  in  excess  of  development  in  relation  to  the  maxillae, 
even  when  the  latter  are  not  out  of  proportion  to  the  other 
bones  of  the  cranium.  In  other  points  of  view,  this  latter 
has  greac  advantage  over  the  former  plan,  inasmuch  as  the 
teeth  are  less  pressed  upon  by  their  neighbors,  whereby  a  very 
fruitful  cause  of  decay  is  removed  ;  and  also  from  the  considera- 
tion that  plates  are  less  frequently  needed,  or,  if  required,  are 
seldom  necessary  for  so  long  a  period. 

But,  if  we  decide  to  treat  a  case  of  irregularity  in  position 
by  the  removal  of  teeth,  the  important  questions  arise,  At  what 
age  is  it  best  attempted  ?  and  what  teeth  shall  be  selected  ? 

With  regard  to  the  age,  much  must  be  left  to  the  discretion  of 
the  [)ractitioner,  and  no  hard  and  fast  rule  can  be  laid  down  ; 
at  the  same  time,  we  express  our  conviction  that  in  many  cases 
the  practice  of  removing  teeth  is  adopted  much  too  soon,  prob- 
ably from  a  disposition  to  lean  to  tlie  wishes  and  persuasions  of 
anxious  parents ;  and  the  result  is,  that  the  spaces  thus  created 
fill  up  too  soon  from  the  vis  a  tergo  of  the  developing  molars, 
which  latter,  in  finding  abnormal  room  in  their  eruption,  fail  to 
effect  that  full  development  in  the  posterior  portions  of  the 
maxillae  which  is  so  dependent  upon  their  presence  in  the  nor- 
mal situations.  We  well  remember  the  case  of  a  youth  whose 
age  did  not  exceed  fourteen,  but  who  had  had  the  four  bicuspids 
removed  from  the  upper  jaw,  as  well  as  several  teeth  from  the 
lower,  to  afford  space.  In  the  upper  jaw  the  first  molars  were 
pressing  against  the  cuspidati  which  were  still  unduly  promi- 
nent, and  the  general  expression  of  the  individual  was  quite 
ruined  liy  the  absence  of  proper  development  in  the  region  of 


IRREGULARITIES    IN    PERMANENT    TEETH. 


97 


the  mouth.  In  another  case,  of  wliich  we  give  an  illustration 
(Fig.  70),  in  the  lower  jaw  on  the  left  side  one,  and  on  the  right 
both,  of  the  bicuspids  had  been  removed  at  an  early  age,  and 
the  spaces  had  quite  closed  up,  but  a  defective  development  of 
the  angle  between  the  ramus  and  the  ascending  portion  of  the 
jaw  had  resulted,  so  that  the  front  teeth  did  not  meet  when 
the  mouth  Avas  closed. 

Other  things  concurring,  we  believe  the  best  period  for  les- 

Fi.tr.  no. 


Result  of  an  early  removal  of  all  of  the  bicuspids  in  the  upper  jaw. 

selling  the  occupants  of  the  dental  arch  will  be  when  the  indi- 
vidual has  just  erupted,  the  second  molars;  and  later  still  if  it 


Fis.  70. 


Result  of  an  earlv  renn 


dcuspids  in  the  lower  jaw. 


be  decided  to   remove  the  first  molars,  and  apply  mechanical 
means  for  devoting  the  space  which  they  occupy  to  the  benefit 

7 


98 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


of  the  anterior  of  the  arch,  as  the  second  molars  will  be  neces- 
sary as  points  of  traction. 

[Dr.  Louis  Jack  has  shown  that  deformities  of  the  month 
from  the  injudicious  extraction  of  the  first  molars  are  twofold. 
First,  when  removed  before  the  second  molars  are  presenting 
through  the  gum,  the  necessity  for  chewing,  and  the  loss  of  the 
grinding  faces  of  these  teeth,  cause  undue  use  of  the  anterior 
teeth  ;  with  unnatural  development  of  the  alveolar  processes  of 

Fio;.  71. 


Deformity  from   too  early  extraction  of  sixth  year  molar. 
(From  Dental  Cosmos.) 

this  region,  the  curving  of  the  lower  jaw,  by  the  contraction  of 
the  cicatrix,  and  tension  of  the  anterior  portion  of  the  masseter 

Fiff.  72. 


Deformity  from  extraction  of  sixtli  year  molar  after  the  eruption  of  the  twelftli  year  molar. 
(I'roui  Dental  Ccsmos.) 

muscles,  and  projection  outwards  of  the  superior  incisors. 
Secondly,  if  the  extraction  be  delayed  until  the  second  molars 
have  fully  erupted,  these   latter   teeth  rnny  lean   towards  the 


IRREOULARITIES    IN    PERMANENT    TEETH.  99 

bicuspids,  and  in  many  cases  the  edges  of  the  grinding  surfaces  of 
their  crowns  meet,  impairing  their  use  for  mastication  and  favor- 
ing the  retention  of  food  in  tlie  trianguhir  space  between  the 
proximal  surfaces  of  tliese  teetli  and  the  gum,  until  decay  may 
add  complication  to  the  trouble  alread}^  existing.'] 

With  regard  to  the  teeth  which  ought  to  be  removed,  it  is 
even  more  difficult  to  lay  down  any  Hxed  rules,  except,  of  course, 
that  we  should,  if  it  can  possibly  ettbct  our  object,  take  by  pre- 
ference teeth  of  abnormal  form,  or  teeth  so  affected  by  disease 
that  there  is  no  certain  prospect  of  their  being  permanently 
saved  ;  and,  indeed,  in  not  attempting  removal  too  soon,  we  may 
often  have  ground  for  satisfaction  in  finding  that  disease  has 
set  in,  in  members  which  it  was  not  our  intention  to  sacrifice. 
On  the  other  hand,  a  very  early  manifestation  of  disease  would 
no  doubt  lead  us  to  prompter  treatment.  Suppo-^ing  that  all 
the  teeth  appear  sound,  and  tiiere  is  no  urgent  reason  for  our 
selecting  certain  teeth  in  preference  to  others,  we  may  be  satis- 
factorily guided  to  our  selection  by  a  consideration  of  the  com- 
parative liability  of  the  teeth  to  disease,  and  information  on  this 
subject  has  been  provided  for  us  by  J.  Tomes,  whose  valual)le 
table  we  copy.^ 

Central  incisors 25 

Lateral        " 63 

Canines 36 

First  bicuspids 227 

Second  bicuspids B03 

First  molars 1 090 

Second  molars 575 

Third  molars 230 

Other  practitioners  have  collected  somewhat  similar  statistics, 
which  in  the  main  agree  with  that  given,  and  the  information 
gathered  therefrom  would  lead  us  to  sacritice  a  first  molar  in 
preference  to  any  other  tooth,  provided  that  in  so  doing  our 
object  could  be  equally  well  accomplished,  and  in  like  manner  a 
second  in  preference  to  a  first  bicuspid.  Cuspidati  we  should 
be  very  loath  to  remove  on  the  ground  also  of  their  being  char- 
acteristic teeth  in  the  dental  arch. 

['  See  proceedings  of  Odontographic  Society  of  Pennsylvania.,  in  Dental 
Cosmos  for  May  1874,  pp.  252  and  253.] 

2  "Analysis  of  2638  cases  of  extraction  on  account  of  caries,"  by  J.  Tomes, 
F.R.S.,  Lectures  on  Dental  Surgery  and  Anatomj'. 


100 


MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY 


The  only  way  in  which  we  can  pretend  to  aid  the  student  in 
this  matter  is,  by  taking:  a  few  tj-pical  cases,  and  the  manner  in 
which  we  should  treat  them.  In  case  1  (Figs.  73,  74),  where 
both  jaws  are  generally  over-crowded,  our  best  course  would  no 


Fitr.  74. 


i'igs.  73  and  74  represent  case  1,  in  which  tlie  removal  of  the  first  molars  from  each  jaw  would 

be  beneficial. 

doubt  be  to  remove  the  four  first  molars.  In  case  2  (Figs.  75, 
76),  where  the  lower  arch,  though  rather  imperfectly  developed, 
contains  the  teeth  in  a  fairly  even  position,  but  the  upper 'arch 
is  Y-shaped,  and  the  front  teeth  are  unduly  prominent,  but  not 
resting  on  the  lower  li[»  when  the  mouth  is  closed,  we  should 


Fiar.  75. 


Fiff.  76. 


KigB.  7i5  and   70  n-jiresent  case  2,  in  which  the  removal  of  the  first  bicuspids  of  the  upper  jaw 

only  is  advisable. 

remove  the  ujipor  first  bicusi)id8  only,  and  the  action  of  the  lips 
would  ]  robably  biing  tlie  projecting  teetli  into  good  position. 


IRREGULARrTIBS    IN    PERMANENT    TEETH, 


lUl 


Should  the  incisors  rest  upon  the  lower  lip,  we  must  in  addition 
make  use  of  the  plate  shown  in  Fig;.  37,  p.  73,  for  drawing  them 

Fig.  78. 


Figs.  77  and  7S  represont  case  2,  before  and  alter  treatment.  The  dotted  lines  show  the  distance 
the  front  teeth  have  beeu  drawn  backwards.  In  79  the  second  permanent  molars  have  been 
erupted. 

backwards.  In  case  3  (Fig;^.  79, 80,)  we  should  in  the  upper  jaw 
remove  the  second  bicuspids,  which  we  should  always  select  in 
preference  to  the  first,  when  any  suspicion  may  exist  that  the 
space  made  may  not  wholly  till  up,  as  well  as  from  their  greater 


Fiff.  79. 


Fi£r.  80. 


'  ,J 


%j:^ 


iK3s*^l 


Fi^'s.  79  and  80  represent  case  3,  in  which  the  remova'  of  the  two  second  bicuspids  from  the  upper 
and  the  right  laterel  incisor  from  itie  lower  jaw  is  to  be  recommended.  [The  principal  difficulty 
attending  this  treatment  has  been  alluded  to  on  page  82] 

liability  to  caries;  we  should  also  adapt  a  plate  to  press  out  the 
lateral  incisors  bitten  over  by  tlie  lower  cuspidati,  and  probably 
also  to  drawback  the  upper  cuspidati;  in  the  lower  jaw  we 
should  remove  the  right  lateral  incisor.  In  case  -4  (Fig.  66, 
p.  94),  where  we  have  not  onl}'  prominent  incisors  resting  upon 
the  lip  when  the  mouth  is  closed,  but  also  a  considerable  nar- 


102    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

rowing  of  the  dental  arch  at  its  sides,  causing  the  bicuspids  and 
first  molars  to  close  more  or  less  within  the  lower  dental  arch, 
we  should,  the  lower  arch  being  well-developed,  expand  the 
upper  by  pressing  out  the  bicuspids  and  first  molars,  and,  when 
this  is  accomplished,  draw  backwards  the  front  teeth.  The 
cases  which  we  have  taken  as  illustrations  could  each  of  them 
no  doubt  be  satisfactorily  treated  in  the  manner  suggested,  as 
many  almost  similar  ones  daily  are,  but  there  are  many  com- 
plications which  arise,  rendering  the  treatment  much  more  diffi- 
cult and  tedious,  and  sometimes  wholly  defeating  our  efforts, 
and  a  few  of  which  we  may  point  out ;  thus,  in  the  case  of  a 
patient's  being  underhung,  we  may  without  difficulty  press  out 
tlie  upper  front  teeth  beyond  the  cutting  edges  of  the  lower, 
but  yet  the  shortness  of  the  former  may,  after  the  discontinu- 
ance of  the  plate,  allow  of  their  return  to  their  old  position, 
and  the  same  thing  may  occur  from  the  back  teeth  meeting  too 
soon.  In  the  first  case  little  can  be  done  bej^ond  wearing  a 
plate  adapted  to  the  palate  only  for  a  long  time  in  order  to  try 
and  retain  the  teeth  in  proper  p)Osition,  and  trust  that  they  may 
drop  somewhat  after  a  time  when  not  bitten  upon;  in  the 
second  case  we  have  often  found  the  chin-retractor  (Figs.  10  and  11 
p.  41),  which  elevates  it  as  well,  of  great  service,  it  being  of  course 
most  applicable  in  very  young  subjects.  We  know  how  the 
constant  tension  of  a  contracting  cicatrix  in  the  neck  of  a  young 
person  will  distort  the  growing  inferior  maxilla,  and  on  the 
same  principle  an  effect  in  the  contrary  direction  may  be  pro- 
duced. But  perhaps  the  greatest  obstacle  to  success  exists  in 
the  cii'cumstance,  that  the  very  means  which  we  employ  for 
overcoming  one  evil  is  productive  of  another  not  less  serious  in 
character,  and  that  the  constant  wearing  of  plates  is  a  most 
fertile  source  of  the  production  of  caries.  Much  may  be  done 
by  tlie  j)atient  no  doubt  to  prevent  this;  thus,  the  plate,  which 
should  never  be  so  attached  but  that  the  patient  can  remove  it, 
should  be  scrupulously  cleansed  with  soap  and  precipitated 
chalk  after  every  meal,  as  well  as  the  teeth  themselves,  and  the 
plate  and  mouth  finally  rinsed  in  a  weak  solution  of  spirit  and 
water.  In  one  very  obstinate  case  we  were  tempted  to  secure  in 
the  mouth  a  plate,  having  the  soft  deal  wedges  before  spoken 
of,  by  ligatures  for  about  ten  days,  when  it  was  seen  that  the 
enamel   had  become  defective  on  all  the  teeth  in  contact  with 


IRREGULARITIES    IN    PERMANENT    TEETH. 


103 


the  we(lo;e9;  an  immediate  discontiiinance  of  the  plate,  and  the 
application  of  salvolatile  to  the  siiots  six  times  in  the  day, 
happily  arrested  all  further  mischief,  at  least  so  far  as  it  was 
possible  to  determine.  The  same  thing  has  occurred  where  a 
platina  band  went  in  front  of  tiie  upper  incisors,  but  which  the 
salvolatile  treatment  appeared  also  perfectly  to  arrest.  We  now 
generally  recommend,  that,  after  thorough  cleansing  of  the 
plate,  all  bands  should  be  wiped  over  with  that  compound. 
The  mischief  is  no  doubt  due  to  the  decomposition  of  the  food 
which  lodges  in  such  places. 

A  question  of  no  little  importance  is  whether,  by  the  timely 
removal  of  temporary  teeth  in  contracted  arches,  more  space 
may  be  afforded  for  their  successors.  It  is  a  subject  to  which  we 
have  long  both  given  and  called  attention,^  having  had  reason 
to  believe  that  thousands,  perhaps  millions  of  unhappy  children 
have  submitted  to  operations  about  as  necessary  as  we  now  re- 
gard those  of  bleeding  and  gum-lancing  as  practised  some  half 
century  ago.  To  take  very  common  cases,  in  the  lower  jaw  for 
instance:  when  that  bone  is  well  developed,  we  shall  observe 

Fig.  81.  • 


Results  of  an  early  removal  of  the  temporary  molars  in  an  ill-developed  lovrer  jaw;  the  first 
permanent  molars  having  advanced  into  an  abnormal  position. 

that,  as  the  period  of  the  second  dentition  approaches,  the  tem- 
porary teeth,  especially  the  six  front  ones,  become  more  promi- 
nent in  the  dental  arch,  and  also  separated,  laterally,  from  each 
other,  80  that,  as  each  drops  out,  room  is  afforded  for  its  successor 
(see  Fig.  30,  p.  67>  In  imperfectly  developed  maxillse  such 
prominence  and  separation  do  not  occur,  so  that  when  the  first 
incisor  is  erupted,  it  will  appear  behind  its  predecessor  and  par- 


•  Vide  Trans.  Odont.  Soc,  old  series,  vol.  iv.  p.  237. 


104    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

tiallj  behind  the  lateral  incisor  of  that  side:  in  like  manner  the 
permanent  lateral  incisor  will  appear  behind  the  temporary  and 
cuspidatus  teeth. 

[To  aid  in  the  expansion  and  normal  development  of  the  jaws, 
the  late  Prof.  McQuillen  always  urged  the  importance  of  pre- 
serving the  deciduous  teeth,  by  filling  and  treating  them  so  that 
their  use  would  be  unattended  by  pain,  and  he  further  recom- 
mended that  food  requiring  considerable  force  for  mastication 
be  given  to  children — such  aliment  being  seemingly  demanded 
from  the  well-known  tendency  of  children  to  gnaw  or  chew 
wood,  roots,  gum,  etc.] 

The  treatment  was,  and  is  unhappily  still,  very  commonly 
adopted  of  removing  all  interfering  temporary  teeth,  to  afford 
the  ijermanent  ones  room  in  the  dental  arch.  It  did  not  occur,  we 
think,  to  those  who  thus  acted,  that  the  limits  of  the  dental 
arch  are  almost  entirely  determined  before  such  treatment 
commences;  that  there  are  fixed  points  to  its  limits  in  the  two 
already  erupted  permanent  molars,  which,  especially  in  crowded 
arches,  are  ever  ready  to  usurp  any  room  afforded  to  them  in 
an  anterior  direction,  as  shown  in  Fig.  81  (p.  103),  where  an  early 
removal  of  the  two  second  temporary  molars  is  followed  by  an 
eruption  of  the  first  two  permanent  ones  in  abnormally  advanced 
positions.  The  same  advance  is  always  met  with  in  normally 
developed  jaws :  the  two  temporary  molars  occupy  a  larger  space 
in  the  dental  arch  than  do  their  successors,  the  two  bicuspids, 
but,  as  soon  as  the  former  are  shed,  tiie  excess  of  space  is  usurped 
by  the  advance  of  the  permanent  molar;  a  fact  which  has  been 
generally  overlooked,  as  it  has  been  stated  that  such  space  is 
accorded  to  accommodate  the  permanent  euspidati.  Figs.  82 
and  83,  drawn  from  normal  pre[)arations,  clearly  illustrate  this 
point. 

In  well-developed  maxillie  the  earlv  removal  of  the  temporary 
teeth  will  have  little  effect  up(^n  the  permanent  dental  arch. 
Cases,  where  all  have  been  removed  before  the  eru[)tion  of  one 
permanent  tooth,  are  taken  to  illustrate  this  point,  but  it  is 
certainly  very  different  in  the  case  of  a  defective  maxilla. 
Thus,  as  in  the  cut  (Fig.  84)  of  a  case  which  we  treated  un- 
fortunately in  this  way  very  man^'"  years  ago,  where  the  incisors 
and  euspidati  of  the  first  series  were  removed  to  accommodate 
the  four  incisors  of  the  second  series,  and  where  everything 


IRREGULARITIES    IN    PERMANENT    TEETH, 


105 


looked  very  satisfactory  up  to  the  eruption  of  tlie  euspidati, 
when   two   bicuspids  had  to   be  removed,  and  a  plate  worn  to 


Fia:.  82. 


Fis;.  83. 


Figs.  82  and  83  show  when  compared  the  usual  advance  of  the  first  permanent  molars  after  the 
shedding  of  the  temporary  molars  ;  and  that  no  room  is  afforded  to  the  teeth  anterior  to  the  first 
molars  by  the  difference  in  size  between  the  temporaiy  molars  and  the  bicuspids. 

accommodate  the  euspidati ;  it  would  have  been  far  better  for 
the  case,  and  much  more  ao;reeable  to  the  patient,  had  we  done 
nothing  farther  than  remove,  if  necessary,  any  temporary  teeth 
whose  successors  had  appeared,  when,  as  in  the  illustration  (Fig. 
85),  one  incisor  would  eventually  have  assumed  a  position  ante- 
rior or  posterior  to  the  dental  arch,  and  its  removal  alone  would 
have  effected  all  that  could  be  desired.  It  must  be  distinctly 
borne  in  mind  that  these  remarks  apply  solely  to  the  treatment 
of  the  lower  jaw,  and  to  the  rule  that  we  would  lay  down — if  it 


106 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY 


be  safe  to  lay  down  any  rule  at  all  in  the  treatment  of  irregu- 
larities in  position — viz.,  simply  to  remove  each  temporary  tooth 
as  its  permanent  successor  a]^pears:  and  this  indeed  not  as  a 


Fig.  84. 


/.  yf 


EesiTlt  of  the  common  treatment  of  removiuy  the  temporary  incisors  and  cuspidati  to  give  room 
for  the  permanent  incisors.  The  incisors  appear  to  be  in  good  position,  but  no  room  is  left  for  the 
permanent  cuspidati. 

matter  of  great  urgency,  the  tongue  always  pressing  forward 
the  teeth  into  any  space  available  for  them.  In  the  upper  jaw 
this  rule  cannot  apply,  as  it  would  often  occur  that  teeth  would 

Fiff.  85. 


Method  of  treatment  by  removing  from  tho  lower  jaw  tlie  temporary  teeth  only  as  their  succes- 
sors appear.  Hero  the  removal  of  the  right  lower  central  incisor  will  be  the  only  treatment 
nece««ary. 

be  kept  within  the  arch,  and  bitten  over  by  those  of  the  lower 
jaw.  The  temporary  teeth  must  be  removed  which  prevent  the 
permanent  ones  from  assuming  their  right  position;  also  the 


IRRE(3ULARITIES    IN     PERMANENT    TEETH, 


107 


Fiir.  85a. 


difference  in  size  of  the  upper  incisor  teeth  with  regard  to  each 
otlier  would,  as  a  rule,  forbid  our  removing  one  of  these  to  afford 
space,  and  we  therefore  generally  select  bicuspids  or  molars. 

We  willingly  confess  to  the  imperfect  manner  in  which  the 
important  subject  contained  in  this  chaj)ter  has  been  treated; 
but  to  have  done  it  more  justice  would  have  involved  a  larger 
space  in  the  volume  than  we  can  afford  to  allot  to  it.  The  student 
desirous  of  investigating  it  more  deeply  may  with  advantage 
consult  the  excellent  work  of  Norman  Kingsley  on  Oral  De- 
formities.' 

[Dr.  M.  II.  Cryer  has  exhibited  an  ingenious  device  for  protect- 
ing the  teeth  from  injury  when  undergoing  pressure,  by  means 
of  the  jack-screws  figured 
on  page  94.  It  consists 
of  thin  platinum  bands, 
encircling  the  teeth,  to 
protect  them  from  in- 
jury where  the  ends  of 
the  screw  impinge. 

The  bands  are  fitted 
and  the  ends  soldered  or 
held  together  by  a  small 
screw  passing  through 
and  binding  them  some- 
what after  the  fashion 
of  Dr.  Farrar's  device. 
Then  by  burnishing  down 
to  the  inequalities  of  the 
teeth,  and  filling  the 
spaces  between  the  band 
and  the  tooth  with  a 
quick  setting  amalgam, 
it  is  made  immovable. 

Into  one  of  these  bands  a  hole  is  drilled  to  receive  the  point 
of  the  jack-screw,  and  upon  the  other  small  lugs  may  be  soldered, 
between  which  the  crotch  ends  of  the  jack-screw  may  fit  tightly, 
and  thus  be  prevented  from  slipping.] 


^•^'mfit 


Bauds  for  protecting  teeth,  to  be  moved  by  jack-screws, 
after  model  by  Dr.  M.  H.  Cryer. 


'  A  Treatise  on  Oral  Deformities  as  a  branch  of  Mechanical  Surger}',  by  Nor- 
man W.  Kingsley,  M.D.S.,  D.D.S.,  etc.     D.  Appletou  &  Co.,  New  York,  1880. 


108    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY, 


CHAPTER    V. 

INJURIES  TO  THE  TEETH. 

Concussion.- — From  violence  caused  by  a  blow  or  fall,  or  where 
the  lower  jaw  has  been  driven  forcibl}^  ao;ainst  the  upper,  one  or 
more  of  the  teeth  may  suffer.  If  slight,  it  may  merely  result 
in  tenderness  and  discomfort  for  a  few  days;  if  more  severe,  it 
may  result  in  the  death  of  a  tooth,  under  which  circumstance' 
the  tooth  after  a  time  usually  assumes  a  pale  fawn  color,  due 
to  extravasation  of  the  vessels  of  the  pulp,  and  consequent 
staining  of  the  dentine  by  the  hsemato-globuline  of  the  blood: 
with  this  exception,  the  tooth  often  continues  for  years'  other- 
wise quite  unimpaired,  but  occasionally  a  small  gum-boil  forms 
over  the  apex  of  its  root.  Or,  again,  a  tooth  so  injured  may 
never  become  quite  lirm,  and  is  usually  lost  at  an  earlier  period 
than  the  rest.  For  such  cases,  rest  for  the  organ,  so  far  as  it 
can  be  obtained  b}'  soft  food,  and  soothing  fomentations  within 
the  mouth,  of  which  camomile  and  poppy  are  the  best,  will  be 
the  only  treatment. 

Dislocation,  partial. — The  same  cause  may  result  in  a  tooth 
being  loosened  in,  and  partially  detached  from,  its  socket,  in 
which  case  the"  alveolus  is  usually  more  or  less  injured,  the 
})eriosteum  lacerated,  and  the  vessels  and  nerves,  which  enter 

'  It  was  our  opinion  until  recently  that  recovery  of  its  proper  color  in  a  tooth 
Ihat  had  once  lost  it,  in  consequence  of  a  blow,  was  impossible  ;  but  a  case 
came  under  our  observation  in  which  there  was  undoubted  evidence  to  the 
contrary,  the  brown  tint  was  gradually  disappearing  from  the  cutting  edge  of 
an  upper  central  incisor  towards  its  neck.  In  such  case  we  appreliend  that 
extravasation  of  blood  had  occurred,  but  not  death  of  the  pulp,  and  that  the 
blood  was  being  absorbed. 

[The  writer  had  a  patient  who,  in  the  lowered  vitality  from  a  dangerous 
attack  of  typhoid  fever,  had  a  lower  incisor  lose  its  translucency  and  present 
tlie  appearance  of  a  dead  tootli,  which,  as  she  regained  her  strength  and  gene- 
ral tonicity,  regained  its  color  until  no  visible  difference  existed  between  it  and 
its  healthy  fellows.] 


INJURIES  TO  THE  TEETH.  109 

at  the  radical  extremity  of  the  tooth,  generally  severed.  In 
such  cases  the  moutli  should  he  washed  with  tepid  water  until 
bleeding  has  ceased,  and  the  tooth  or  teeth  pressed  carefully 
between  the  finger  and  thumb,  and  steadily  but  forcibly  back 
into  their  proper  positions,  whilst  the  same  members  of  the 
other  hand  should  simultaneously  reduce  any  displaced  portions 
of  alveolus.  The  above-mentioned  applications  for  concussion 
may  be  employed,  but  great  tenderness  mny  be  often  relieved 
by  the  ai)}»lication  of  one  or  two  leeches  to  the  neighboring 
part. 

[Dr.  C,  a  graduate  of  both  dentistry  and  medicine,  several 
years  since  had  liis  lower  incisors  and  tiie  anterior  plate  of  the 
alveolar  process  pulled  over  the  lower  lip  by  a  liorse  stumbling 
while  the  rider  was  putting  on  gloves,  and  tem[)orarily  holding 
the  reins  in  his  mouth.  The  teeth  were  immediately  pushed 
back  into  their  proper  position,  and  now  appear  as  natural  as 
the  adjacent  ones.] 

Dislocation,  complete. — Should  this  result  of  violence  occur, 
the  mouth  should  be  washed  until  bleeding  has  ceased,  when 
the  alveolus  is  cleared  of  coagula  by  cotton,  and  afterwards  by 
the  syringe  and  tepid  water,  to  insure  removal  of  any  i)articles 
of  cotton,  tartar,  etc.;  and  the  tooth  or  teeth,  as  the  case  may 
be,  which  should  be  freed  from  all  foreign  substances  and  kept 
immersed  in  tepid  water  during  the  interval,  carefully  but 
firmly  replaced  in  their  sockets,  and  the  alveoli,  probably  more 
injured  tlian  in  the  former  cases,  moulded  to  their  sides  as 
before.  In  almost  all  the  cases  now  under  consideration,  the 
teeth  thus  treated  will,  after  a  day  or  two,  appear  elongated  in 
their  sockets,  and  looser  than  when  replanted,  but  this,  the 
result  of  effusion,  generally  passes  oft"  in  the  course  of  a  few 
days.  If  the  alveolar  process  has  not  been  much  injured,  the 
operation  is  generally  successful,  and  we  should  not  despair  of 
success  even  where  a  tooth  has  been  out  of  the  mouth  for 
several  hours.  We  shall  again  refer  to  this  subject  in  the 
chapter  on  Replantation  and  Transplantation. 

[Dr.  H.  E.  Pfliiger  reports  having  known  teeth  with  extirpated 
jiulps  to  again  have  the  cavities  filled  with  sensitive  vascular 
tissue  resembling  the  original.  Prof.  McQuillen  exhibited 
before  the  Odontographic  Society  and  Academy  of  ^'^atural 
Sciences,  in   Philadelphia,  a    pigeon   whose  cerebrum   he   had 


110    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

four-fifths  extirpated,  and  which  regained  the  lost  functions. 
The  cranial  cavity  was  refilled  with  tissue  that,  on  microscopic 
examination,  presented  the  appearance  of  typical  nerve  cells. ^] 

As  the  result  of  violence,  an  accident  almost  the  reverse  of 
dislocation  may  occur,  viz.,  where  a  tooth  is  driven  into  and 
beyond  its  alveolus.  It  is  more  likely  to  occur  to  the  teeth  of 
the  upper  than  to  those  of  the  lower  jaw,  and  in  some  cases 
has  even  effected  a  perforation  of  the  floor  of  the  nares.  The 
treatment  here  will  be  to  brin;^  the  tooth  down  to  its  proper 
level  by  the  aid  of  forceps;  and  in  this  case  a  ligature  attached 
to  an  adjoining  tooth  or  adjoining  teeth,  to  retain  it  in  situ, 
may  be  essential ;  and  there  can  be  no  objection  to  the  employ- 
ment of  a  ligature,  as  plenty  of  space  in  the  alveolus  will  exist 
for  any  exudation  to  occupy.  In  the  case  of  ordinary  disloca- 
tion, as  we  have  described  it,  we  do  consider  the  ligature  of  the 
replaced  tooth  to  its  neighbors,  as  generally  recommended, 
objectionable,  as  it  prevents  the  effusion  of  lymph  into  the 
alveolus,  which  fornis  the  medium  of  union  between  the  severed 
portions  of  the  alveolo-dental  membrane. 

[The  writer  has  a  child,  who  fell  and  drove  the  crowns  of 
both  superior  deciduous  central  incisors  up  into  the  gum,  one 
almost  out  of  sight.  They  were  at  once  drawn  down  by  forceps 
to  their  original  position,  A  few  weeks  after,  the  one  most 
displaced  by  the  first  accident,  was  again  driven  up  by  a  similar 
fall.  This  tooth  was  a  second  time  drawn  down,  but  never 
recovered  com))letely,  as  it  soon  showed  unmistakable  signs  of 
death  of  the  pulp  and  was  shed  a  year  or  so  afterwards,  in 
advance  of  its  fellow  and  the  presentation  of  the  permanent 
teeth — which  latter,  however,  came  properly  into  position,  and 
now,  as  when  erupted,  are  to  every  test  normal.] 

Fracture  of  the  teeth  may  be  another  consequence  of  violence, 
and  may  vary  in  amount  from  slight  chipping  of  the  enamel  to 
conijtlete  division  at  the  neck  or  elsewhere.  Where  very  slight, 
it  may  be  attended  with  no  further  result  than  its  unsightli- 
ness.  Should,  however,  a  portion  of  the  dentine  be  involved,  it 
will  be  generally  very  sensitive  when  touched,  and  also  to  heat 
and  cold  for  some  time;  l)ut,  if  fractured  so  as  to  expose  the 

['  Prnccodings  of  Odontographic  Socii-ty  of  Pennsylvania  and  Proceedings  of 
Academy  of  Natural  Sciences  of  Philadelphia,  Feb.  4,  1878,  p.  343.] 


INJURIES    TO    THE    TEETH.  Ill 

pulp,  there  will  be  considerable  pain  on  the  slightest  contact  of 
even  soft  substances.  Fracture  may,  of  course,  be  complicated 
with  partial  or  complete  dislocation. 

Treatment. — In  the  first  simple  cases  we  may,  by  a  judicious 
employment  of  the  file,  often  lessen  the  unsightliness;  thus,  if 
the  chip  be  at  the  cutting  edge  of  an  incisor,  we  may,  by  round- 
ing it  oif,  and  slightly  shortening  the  tooth,  render  it  scarcely 
conspicuous.     When  the  dentine  lias  been  exposed,  especially  in 
a  young  subject,  we  must  wait  until  the  sensitiveness  has  passed 
off  (which  may  be  accelerated  by  the  application  of  salvolatile  or 
solution  of  zinc  chloride)  before  the  file  can  be  employed,  and 
we  may  often  with  advantage  sacrifice  a  little  of  the  enamel  of 
the   contiguous    teeth.     When,  however,  the   tooth   has  been 
much  fractured,  and  especially  if  the  pulp  has  been  exposed, 
one  of  two  alternatives  must  be  adojited, — either  the  destruction 
of  the  pulp,  or  the  removal  of  tlie  tooth, — our  decisions  as  to 
which,  will  depend  upon  the  nature  of  the  fracture,  the  age  at 
which  it  occurs,  the  crowding  or  otherwise  of  the  teeth,  and 
their  relative  sizes.     Should  the  fracture  include  more  than  a 
small  portion  below  the  neck  of  the  tooth,  or  be  accompanied 
with  much  injury  to  the  alveolus,  we  should  without  hesita- 
tion at  once  extract.     Should  it  occur  in  a  patient  over  fifteen 
years  of  age  whose  teeth  are  not  crowded,  and  should  the  frac- 
ture not  extend  obliquely  below,  or  much  below,  the  surface  of 
the  gum,  we  should  adopt  the  former  plan,  the  process  for  which 
we  shall  hereafter  describe,  and  8U[)ply  the  patient  with  an  arti- 
ficial tooth  to  be  attached  to  the  root  of  the  fractured  tooth. 
Should,  however,  the  patient  be  under  fifteen,  when  the  fang  of 
an  incisor  or  cuspidatus  is  not  fully  developed,  and  also  when 
there  exists   no    very  marked    difference   in   size  between  the 
various  front  teeth,  with  es[)ecially  a  tendency  to  crowding,  or, 
at  all  events,  to  the  teeth  not  being  separated  from  each  other, 
we  shall  then  do  best  to  extract,  as  we  may  feel  pretty  sure  that 
without,  but  alniost   certain   that   with,   mechanical    aid,  the 
space  will  in  time  be  quite  filled  up.     We  removed,  about  two 
years  ago,  a  large  upper  central  incisor  from  the  mouth  of  a 
little  girl  aged  ten,  and  a  year  afterwards  its  fellow:  the  lateral 
incisors  now  meet  closely  together,  and  the   mouth   looks  far 
better  than  it  did  at  first,  as  the  teeth  in  question  were  abnor- 
mally developed.     The}-  were  removed  on  account  of  caries. 


112    MANTAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

[This  recalls,  of  two  cases  bearing  upon  the  subject,  one  of 
u  young  lady  who  had  lost  the  left  central  incisor  at  lifteen, 
Avhich  space  was  completely  obliterated,  and  the  mouth  and 
teeth  were  comely  and  shapely  ;  the  other  of  a  lad  of  eleven  years, 
whose  central  incisor  was  broken  by  a  stone  thrown  against 
the  tooth,  s[)litting  the  root  longitudinally,  and  completely 
destroying  the  crown.  Acting  ujjou  the  experience  of  the  first 
case,  wdjich  was  originally  under  the  care  of  another  dentist,  this 
Avas  similarly  treated  and  the  remains  of  the  root  were  at  once 
removed.     Within  four  years  the  space  lias  almost  closed.] 

The  uniting  of  the  portions  of  a  fractured  fang  is  so  very  rare 
an  event  that  we  can  hardly  ever  look  for  its  occurrence  ; 
nevertheless,  as  cases  have  been  recorded,  we  should  at  all 
events  be  in  no  great  hurry  to  extract  where  such  event  has 
occurred.  The  favorable  cases  would  no  doubt  be  in  young 
persons,  where,  of  course,  the  vitality  of  the  pulp  has  not  been 
destroyed  or  the  periosteum  much  injured.  The  medium  of 
union  in  such  cases  appears  to  be  cementum,  but  the  pulp  in 
the  region  of  the  fracture  had  in  one  case  recorded  become 
calcified.  Teeth  fractured  by  violence  in  their  fangs  may  be 
retained  with  moderate  firmness  Iw  the  periosteum  for  some 
time,  but  they  sooner  or  later  become  a  source  of  inconvenience, 
and  the  crown  portion  either  has  to  be  removed,  or  becomes 
loose  a)id  drops  out;  still  we. have  seen  them  so  retained  for 
several  years.  Two  cases  are  recorded  where  a 
^  ■  tooth  had  been  fractured  by  violence,  and  the 
crown  portion  removed,  but  the  pul[»  left  had 
been  converted  into  secondary  dentine  of  more 
than  normal  dimensions;  also  another,  where  the 
same  accident  occurred,  but  where  the  surface  of 
the  retained  portion  became  coated  with  cemen- 
tun].^  The  only  recorded  case  of  impacted 
■",    .        fracture  of  a  tooth  is,  we   believe,  one   we  com- 

Ca»c      of      im-  ' 

imcted    fracture    muuicated  to   the   Odoiitological    Society.^      The 
)n  an  upper  inci-  ^^       interesting,  inasmuch   as  the  existence 

wor    tooth.      llie  o" 

two      fragment     of  thc  tVacturc  was  uot  discovcrcd  until  after  the 

(love-tail  into      ,        ,,  ^         ^      i         •.  ^      i 

.•arh  other.  tootl)   was    cxtractcd  ;    it   was    an    upper   central 

'  A  System  of  Dental  Snrgeiy,  by  John  Tomes,  F.R.S. 
'^  Trans.  Odont.  Soc,  vol.  xi.  p.  140. 


INJURIES    TO    THE    TEETH.  llo 

incisor,  and  one  practitioner  of  eminence  had  even  drilled 
through  the  crown,  and  j)arlially  removed  the  contents  of  and 
filled  the  pulp-cavity  to  relieve  periostitis,  without  jterceiving 
the  mischief.  It  occurred  in  the  person  of  a  youth  of  fourteen, 
and  was  certaitdy  a  most  favorable  case  for  re-union,  as  the 
two  fragments  were  immovable  and  kept  in  accurate  position 
for  three  years,  but  the  violence  of  the  shock  had  caused  death 
of  the  pulp. 

Under  the  term  "dilaceration"  J.  Tomes  has  described  a  con- 
dition supposed  to  be  due  to  violence,  in  which  the  crown  of  a 
tooth  is  found  bent  at  a  considerable  angle  to  its  fang  ;  a  section 
in  such  a  case  will  exhibit  the  dentinal  tubules  abruptly  bent  or 
deviated  at  such  angle.  We  have  ever  been  inclined  to  regard 
sucli  deviation  as  more  deiiendent  upon  the  ordinary  lines  of 
development  having  become  abruptly  altered  ;  and  this  view 
has  been  entertained  by  others:^  at  tlie  same  time,  a  blow  or 
other  violence  might  readily  determine  an  altered  course  of 
development,  which  we  can  readily  comprehend  if  we  adopt  the 
views  already  given  with  regard  to  the  growth  of  bone  resulting 
in  the  eruption  of  the  teeth  ;  thus,  in  a  tooth,  the  crown  of  which 
is  just  or  nearly  develojied,  any  condition  that  would  cause  tlie 
surrounding  growing  bone  to  advance  to  the  surface  in  an  altered 
direction  would  naturally  alter  the  relationship  of  that  portion 
of  the  tooth  to  the  rest.  In  a  very  well  marked  case  of  this  de- 
formity, a  central  incisor  of  the  upper  jaw,  which  we  handed 
to  J.  Tomes,  and  which,  we  believe,  he  has  figured  in  one  of  liis 
works,  there  was  a  distinct  history  of  violence  at  the  period  when 
the  crown  of  such  tooth  would  have  been  nearly  calcified,  but 
the  character  of  the  violence  rendered  it  difficult  to  imagine  that 
its  results  could  have  affected  one  tooth  only,  or  have  affected  it 
80  as  to  cause  its  being  so  much  bent  upon  its  fang. 

'  The  Pathology  of  the  Teeth,  by  Carl  Wedl. 


114    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY, 


CHAPTEE    VI. 

DENTAL  CARIES. 

To  the  dental  practitioner  there  can  be  no  subject  more  im- 
portant or  interesting  tlian  the  disease  which  bears  the  above- 
mentioned  designation,  for  of  the  cases  which  come  before  him 
some  ninety  per  cent,  will  most  probably  be  more  or  less  depend- 
ent upon  its  presence  or  its  results.  Its  interest,  too,  is  enhanced 
by  the  fact  that  it  is  a  disease  much  more  common  to  civilized 
than  to  uncivilized  communities,  and  is  undoubtedly,  but  le?s 
happily,  like  civilization,  greatly  on  the  increase.  That  such  is 
the  case,  we  accept  again  the  experience  of  those  who  have  had 
under  observation  the  mouths  of  several  generations  in  the  same 
families,  as  well  as  avail  ourselves  of  the  results  of  our  own 
practical  examination  of  the  skulls  of  past  generations  as  com- 
pared with  those  of  individuals  now  living.^  There  is,  probably, 
no  disease  so  common  to  the  civilized  portion  of  the  human  race 
in  the  present  day  as  dental  caries;  so  much  so,  that  it  is  rare 
to  find  a  mouth  in  which  some  manifestation  of  its  ravages  is 
not  present,  or  an  individual  so  fortunate  as  to  have  never  ex- 
perienced the  pain  which  commonly  accompanies  it.  IlTeverthe- 
less,  it  is  remarkable  that  no  one  amongst  its  numerous  and 
talented  investigators  has  yet  offered  for  a  disease  so  common 
and  ap[>arently  so  favoral)le  for  observation  an  explanation  of 
its  causes  or  nature  that  has  been  at  all  generally  accepted  by 
dental  practitioners.  The  most  diversified  and  opposite  views 
have  been  i)Ut  forward,  and  to  the  speculative  here  are  theories 
to  the  heart's  content.  It  will  be  our  duty  to  notice  the  most 
important  of  these,  but  we  shall  first  attempt  to  describe  what 
actually  takes  place  if  we  watch  the  disease  from  its  commence- 
ment to  its  termination. 

According  to  our  own  observations,  made  when  it  has  com- 

'  Trans.  Odont.  Soc,  vol.  iv.  p  227,  old  series. 


DENTAL    CARIES.  115 

menced  in  positions  favorable  for  observation,  the  first  mani- 
festation of  its  existence  bas  been  a  small  whitish  o[)aque  spot 
on  the  enamel  as  contrasted  with  the  yellowish  and  somewhat 


A  section  of  tooth  affected  with  caries.  On  the  upper  part  at  the  ri{,'ht  side  will  be  seen  a  small 
piUtion  of  enamel  involved  ;  the  rods  appear  more  distinct  than  when  normal,  and  also  exhibit 
the  transverse  markings.  In  the  affected  dentine  the  tubuli  appear  more  distinct,  with  tendency 
to  separate  from  each  other ;  the  di.seased  portions  are  seen  dipping  down  amongst  the  healthy 
structure  in  the  direction  of  the  pulp  cavity.  That  portion  situated  between  the  diseased  and 
healthy  tissue,  and  where  the  markings  of  the  tubuli  are  less  distinct,  is  the  translucent  zone  of 
Tomes.    (From  a  section  in  possession  of  the  author.) 

opalescent  appearance  of  that  structure.  In  its  progress  it  gene- 
rally assumes  a  somewhat  darker,  light  brown,  or  fawn  color, 
though  this  much  depends  ujion  the  rate  of  its  progress,  for 
where  tins  is  very  rapid,  a  light  color  is  maintained  through- 
out. Microscopical  examination  at  the  earliest  stages,  which  it 
is  difficult  to  conduct  owing  to  the  friable  nature  of  the  enamel,^ 
shows  this  structure  to  possess  an  orange-brown  hue  in  the  parts 
affected,  especially  in  the  basis-substance  of  the  enamel  rods, 
which  latter  have  their  outlines  more  distinct  than  when  nor- 
mal:  they  also  present  transverse  markings  which  are  seldom 
seen,  or  seen  distinctly,  in  the  perfect  tissue.     In  the  interstices 

'  Dr.  Frank  Abbott,  Dental  Cosmos,  vol.  xxi.  p.  59,  recommends  the  follow- 
ing method  as  emplo3-ed  by  Dr.  Bodccker,  viz.  :  — 

A  section  sawn  frcmi  a  carious  tooth  perfectly  fresh  should  be  ground  by  a 
corundum  wheel  under  the  surface  of  water,  and,  when  sufficiently  thin,  im- 
mersed in  a  dilute  solution  of  chromic  acid,  viz.,  |  per  cent.,  for  tAventy-four 
hours :  it  should  be  then  stained  in  carmine  solution  and  mounted  in  a  mixture 
of  glycerine  and  water,  two  parts  of  the  former  to  one  of  the  latter. 


lllj         MANUAL    OF    DENTAL    SURGERY    AND    PATUOLOGY. 

between  the  enamel  rods  some  investigators^  have  discovered 
delicate  beaded  fibres,  which  may  be  stained  by  carmine,  whilst 
on  the  outer  surface  appear  fiat  epithelial-like  bodies,  supposed 
to  be  the  remnants  of  ll^asmyth's  membrane.  At  the  earliest 
stages,  when  only  the  enamel  is  aft'ected,  we  find  no  traces  of 
lejitothrix  or  micrococci,  to  the  presence  of  which  in  causing  or 
promoting  dental  caries  some  writers  have  attached  much  im- 
portance. 

[A  theory  has  been  advanced  that  these  parasites,  which  may 
be  found  in  mouths  where  the  teeth  are  perfectly  sound  and 
without  any  unfilled  cavities  of  decay,  have  lodged  in  the 
carious  places  simply  as  locations  where  they  are  partially  pro- 
tected from  dislodgment  by  the  breath,  drink,  or  food,  as  fissured 
rocks  will  sui^port  vegetable  or  animal  life  in  the  crevices,  while 
the  smooth  surfaces,  exposed  to  the  winds  and  rains,  are  bare  (^f 
vegetation.] 

As  the  disease  advances,  the  subjacent  dentine  becomes  in- 
volved, and,  it  being  a  much  less  dense  and  less  homogeneous 
structure  than  the  enamel,  the  disorganization  takes  place  in  it 
more  rapidly,  the  lime-salts  disappear,  leaving  the  gelatinous 
basis-substance  much  in  the  same  condition  as  it  was  when  its 
calcification  took  place.  In  some  cases,  those  of  so-called  chalk}' 
decay,  it  would  ai>pear  as  if  the  calcified  structure  broke  down 
at  once.  In  both  the  enamel  and  dentine  the  greatest  destruction 
appears  at  the  outer  surfaces,  z.  e.,  the  part  first  attacked,  for 
dental  caries  arises  from  without,  not  from  within,  a  tooth,  and 
this  will  give  to  th-e  parts  atfected  cone-like  forms;  in  the  enamel 
one  having  its  base  at  the  surface  whilst  its  truncated  apex  is  in 
apposition  to  the  base  of  that  of  the  dentine,  which  is  a  larger 
and  more  [lerfect  representation  of  tliis  figure.  In  the  dentine 
it  imrsucs  its  course  in  the  direction  of  the  dentinal  tubuli,  i.  c, 
towards  the  pulp-cavity  into  which  they  open,  ^^licroscopical 
examination  at  this  period^  shows  the  enamel  more  broken  up 

'  Dr.  Frank  Abbott,  Dental  Cosmos,  vol.  xxi.  p.  62. 

2  Dr.  Frank  Abbott,  op.  cit.,  recommends  the  following  process  :  The  carious 
tooth,  or  a  suitable  portion  of  it,  sliould  be  immersed  for  two  months  in  a  1  per 
cent,  solution  of  chromic  acid,  to  wliich  a  few  drops  of  dilute  hydrochloric  acid 
should  be  added  every  other  day,  the  mixture  being  changed  weekly  ;  at  the 
•end  of  the  two  months  the  tooth  should  be  embedded  in  warm  paraflfine,  to 
which  a  little  beeswax  has  been  added,  and,  when  it  is  cold,  sections  should 
be  cutoff  with  a  razor,  stained  with  carmine,  and  mounted  in  the  glycerine 
solution. 


DENTAL    CARIES 


117 


and  disorganized  than  in  the  former  case,  and  the  subjacent 
dentine  of  a  yellowish  color,  having;  festoon-slinped  boundaries 
sei)arati!ig  it  from  the  healthy  structure;  whilst,  especially  in 
acute  cases,  portions  having  the  j-ellow  color  are  seen  dipping 
down  at  some  distance  from  the  principal  centre  of  the  disease 
towards  the  |)ulp-cavit3'.  At  the  margin  of  the  diseased  struc- 
ture the  dentinal  tubuli  ajipear  less  distinct  than  they  do  in  the 
l>erfectl3^  healthy  tissue  nearer  the  i)ul})-cavity  ;  viewed  with  a 
low  power  this  portion  has  a  zone-like  form,  the  zone  of  Tomes, 
who  regarded  it  as  a  consolidation  of  the  contents  of  the  tubuli, 
an  effort  of  nature,  in  fact,  to  put  a  barrier  between  the  healthy 
and  diseased  structures  ;  other  and  later  observers  have,  however, 
regarded  it  as  a  result  of  diseased  action  producing  an  absolute 
exclusion  of  air  from  the  tubuli,  thus  rendering  them  invisible 
when  viewed  hy  transmitted  light,  but  amongst  several  living 
authorities  the  views  of  J.  Tomes  are  still  adopted.     [Fig,  89 


Fig.  88. 


[Fig.  89. 


The  tobacco-pipe-stem  appearance(Tonies)  ;  the  drawing 
is  made  from  a  specimen  of  the  chalky  decay. 

was  drawn  from  a  microscopical  sec- 
tion made  from  a  tooth  where  the 
translucent  zone  was  found  beneath  a 
gold  filling.  Prof.  McQuillen  had  a 
section  where  this  zone  was  shown  to 
have  formed  under  a  retaining  pit  in 
a  tooth  that  had  been  successfully  filled  with  gold.]  At  the 
more  aftected  portions,  i.  c,  nearer  to  the  surface,  we  observe 
the  tubular  structure  of  the  dentine  to  be  more  apparent  than 
in  the  healthy  tissue,  and  for  the  reason,  doubtless,  that  the  in- 
tertubular  substance  is  the  first  to  be  attacked,  the  walls  or 
external  portions  of  the  tul)uli  appearing  to  possess  a  e:reater 
power  of   resistance.      When  the  disccised  portion   is   seen    in 


Translucent  zone  in  a   tooth    that 
had  been  filled  with  guld] 


118 


MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 


transverse,  or  in  partially  transverse,  sectioii,  its  appearance 
reminds  us  of  a  bundle  of  tobacco-pipes  when  broken  short  off 
in  their  stems,  as  described  and  ligured  by  J.  Tomes.^  But  a 
section,  cut  so  as  to  exhibit  the  results  of  the  disease  at  various 
distances  from  the  surface  and  viewed  by  a  very  high  power,^ 


Fis;.  90. 


^^' 


Cross-section  of  carious  dentine  magnified  1000  diameters,  copied  from  Dr.  Frank  Abbott's  ex- 
ceHent  paper  in  the  Dental  Cosmos  (vol.  xxi.  p.  117)  ;  a,  canaliculi,  with  radiated  offshoots,  in 
the  healthy  tissue  ;  6,  the  same  enlarged  by  extension  of  disease  and  exhibiting  granules  and 
threads  which  take  up  carmine  ;  c  and  d,  the  same  more  affected  by  disease  ;  e,  canaliculi  enlarged 
to  ten  or  fifteen  times  their  ordinary  diameters,  and  filled  with  partly-nucleated  protoplasm  ;/and 
g,  confluence  of  two  or  more  canaliculi  ;  h,  basis  substance  entirely  disappeared,  and  beyond  this 
a  disintegrated  mass  composed  probably  in  great  part  of  micrococci. 

shows,  at  its  neighborhood  to  the  healthy  tissue,  the  canaliculi 
unaflected ;  but  as  the  decayed  surface  is  approached,  these  are 
enlarged,  and  tilled  apparently  with  granules  and  threads,  which 
receive  the  staining  of  carmine;  still  nearer  to  the  surface  they 
are  enlarged  to  two  or  three  times  their  normal  diameters, 
exhibiting  within  them  a  network  of  living  matter,  and  occa- 
sionally, where  more  enlarged,  nuclei  also.     Further  outwards 

'  System  of  Dental  Surgery,  2cl  edit.  p.  29R. 

*  Dr.  Frank  Abbott,  Dental  Cosmos,  vol.  xxi.  p.  IIG. 


DENTAL    CARIES, 


119 


they  are  so  extended  that  several  become  confluent;  as  this 
increases,  the  hasis  substance  disappears,  the  outern)ost  layer 
consisting  of  a  disintegrated  mass  of  tissue  mixed  up  with 
micrococci  and  liptotlirix. 


Fio;.  91. 


Fragment  of  dentine  covered  on  its  surface,  and  interstices  with  leptotlirix  and  micrococci. 
The  drawing  must  be  regarded  as  diagrammatic  rather  than  accurate. 


If  a  portion  of  carious  dentine  be  tested  with  litmus-paper, 
it  will  be  found  to  possess  a  strong  acid  reaction,  wliilst  in  a 
healthy  tooth  the  dentine — probably  the  contents  of  the  cana- 
liculi — yields  a  decidedly  alkaline  reaction.  The  acid  reaction 
of  carious  dentine  we  have  accounted  for  by  the  neutral  phos- 
phates of  lime  which  are  incorporated  with  the  basis  substance 
becoming  converted  into  the  soluble  acid  phosphate,  the  hypo- 
phosphate  of  lime. 

To  revert  to  our  general  observation  of  the  process,  we 
next,  probably,  get  the  eflects  of  mechanical  strain  on  the 
enamel,  which  is  imperfectly  supported  by  the  subjacent  soft- 
ened dentine,  and  breaks  down,  leaving  a  more  or  less  exposed 
cavity.  Where  the  disease  has  been  very  rapid  and  interstitial, 
I,  e.,  occurring  between  teeth,  the  breaking  of  the  enamel  is  often 
the  first  intimation  to  tlie  patient  of  what  has  existed,  he  not 
unfrequently  attributing  the  fracture  to  an  accident  in  mastica- 
tion, and  the  decay  as  sequence  to  and  result  oi  the  accident : 
where  it  has  been  less  rapid,  the  enamel  disintegrates  in 
minute  particles.     In  both  cases  the  progress  of  the   disease 


120        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

becomes  more  rapid  when  an  actual  cavitj'  exists,  one  at  least 
that  can  readily  retain  portions  of  food,  and  ere  long  in  the 
natural  order  of  events  the  pulp-cavity  becomes  invaded. 
Such,  however,  is  not  always  the  case,  for  it  may  happen,  and 
this  is  more  likely  where  the  disease  advances  very  slowly, 
that  the  pulp  becomes  calcified — converted,  that  is,  into  Avhat 
has  been  termed  secondary  dentine;  and,  indeed,  in  almost  all 
cases,  even  in  the  most  rapid,  we  shall  find  that  some  attempt, 
the  result  no  doubt  of  irritation,  has  been  made  by  the  pulp  in 
this  direction. 

The  consequence  of  exposure  of  the  pulp  is  usually  its 
inflammation,  and,  owing  to  the  attendant  effusion  into  a 
structure  surrounded  with  unyielding  walls,  the  pain  set  up  is 
generally  most  acute;  in  many  cases,  however,  we  find  the  pulp 
exposed  in  the  progress  of  caries  where  pain  has  never  been 
experienced,  except,  perhaps,  when  pressed  upon  by  food,  and 
where  we  may  doubtless  rightly  infer  that  severe  inflamnjatory 
action  has  never  set  in.  Pain  is,  however,  often  felt  before  the 
pulp  is  actually  exposed  ;  sometimes  in  the  very  earliest  stages, 
and,  indeed,  in  a  few  cases,  before  any  actual  manifestation  of 
the  disease  is  discernible,  but  where,  at  the  spot  referred  to,  the 
disease  after  a  time  makes  its  appearance.  Exposure  of  the 
pulp  is  usually  attended  with  ulceration  of  its  surface,  and  with 
such  ulceration  more  or  less  exudation  of  serous  or  sangui no- 
serous  fluid.  Tliis  has  generallj^  been  spoken  of  as  suppuration 
of  the  pul[t;  but,  althougli  actual  pus  may  occasionally  be 
formed  by  the  pulp,  it  is  very  dift'erent  from  the  first-named 
fluid,  and  contains  only  a  small  proportion  of  the  debris  of  the 
white  corpuscles.  The  crimson  surface  of  an  exposed  pulp  is 
most  comparable  to  that  of  the  "irritable  ulcer,"  and  the  fluid 
exuded  not  dissimilar,  exce})t  that  it  decomposes  more  rapidly, 
emitting  a  most  otfensive  cadaverous  smell.  Tlie  reaction  of 
this  fluid  is  alkaline,  and  it  certainly  tends  to  neutralize  the  acid 
condition  of  the  dentine  at  least  at  the  surface,  for  we  have 
found  it  acid  a  short  distance  below,  and  thus  probably,  as  lias 
been  pointed  out,  to  some  extent  retards  the  progress  of  the 
disease,  whilst  the  pulj)  gradual!}'  sloughs  away  more  or  less 
rapidly.  The  pulp  being  lost,  the  dentine  softens  ra[)idly,  the 
enamel  breaking  away  as  its  support  is  withdrawn  from  it, 
until  tiie  carious  surface  becomes  level,  or  nearly  so,  with  tiie 


DENTAL    CARIES.  121 

surroundiiio:  sjnni,  wliere,  from  protection  of  surface  hy  the 
latter,  aided  probably  by  that  other  protection  aojainst  decom- 
position which  livinor  substances  exert  towards  organic  bodies 
in  their  immediate  vicinity,  the  softening  of  the  dentine  of  the 
fang  or  fangs  advances  much  more  slowly.  Still  the  residue, 
gradually  carried  to  the  surface  by  the  process  which  we  have 
described,  becomes  continually  diminished  until  its  hold  on  the 
mucous  membrane  is  so  slight  that  it  falls  away  under  the 
friction  of  tlie  tongue  or  in  mastication.  Such,  then,  is  the 
ordinary  career  of  a  carious  tooth  from  its  commencement  to  its 
end.  Many  variations  in  the  process  occur,  but  the  conditions 
above  described  may  be  considered  typical  ;  and  now  the  far 
more  difficult  task  devolves  upon  us  of  attempting  to  describe 
briefly,  and  with  justice  to  tlie  authors,  the  various  theories 
whicl)  have  been  propounded  to  account  for  it. 

Hunter,  who,  amongst  modern  pathologists,  was  one  of  the 
first  to  investigate  dental  diseases,  and  give  to  them  the  promi- 
nence which  they  deserved,  denominated  this  as  "the  decay  of  the 
teeth  arising  from  rottenness;"  but  that  he  implied  something 
difterent  from  what  we  now  generally  comprehend  by  slow 
chemical  decomposition  of  animal  or  vegetable  substances  is 
evident  from  his  statement  "  that  such  decay  would  appear  to 
deserve  the  name  of  mortification;"  and  still  something  more, 
for  "  the  simple  death  of  the  part  would  produce  but  little  effect," 
and  he  suspects  that  during  life  there  is  some  operation  going 
on  which  produces  a  change  in  the  diseased  part.  When  it 
attacks  the  bony  part  of  a  tooth,  it  appears  first  to  destroy  the 
earth,  as  the  bony  part  becomes  softer  and  softer.  It  begiiis 
sometimes  in  the  inside  of  a  tooth,  although  but  rarely:  if  it 
always  so  commenced,  it  might  have  been  supposed  to  arise 
from  a  deficiency  of  nourishment  from  some  fault  in  the  vascular 
system,  but,  as  it  most  commonly  begins  externally,  where  the 
teeth  in  their  most  sound  state  receive  little  or  no  nourishment, 
it  cannot  be  referred  to  that  cause.  It  does  not  arise  from 
external  injury  or  from  menstrua,  which  have  a  power  of 
dissolving  part  of  a  tooth,  for  such  could  not  act  so  partially  ; 
and  it  is  reasonable  to  su[)pose  that  it  is  a  disease  arising 
originally  in  the  tooth  itself,  because,  when  once  the  shell  of  the 
tooth  has  given  way  to  the  cavity,  the  cavity  itself  soon  becomes 


122        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

diseased  in  the  same  way:  in  a  sound  tooth  broken  by  accident 
no  such  quick  decay  ensues. 

From  a  perusal  of  Hunter's  work,'  it  can  scarcely  be  gathered 
that  that  great  man  held  any  very  distinct  theory  or  definite 
views  upon  the  causes  and  nature  of  dental  caries ;  although 
with  regard  to  it,  and  what  is  observed  duringi  its  progress, 
he  writes  with  a  clearness  which  is  a  characteristic  of  all  his 
works. 

Fox,2  who  wrote  about  a  quarter  of  a  century  later  than 
Hunter,  alludes  to  the  disease  as  "caries,  or,  as  it  is  most  coni- 
monly  called,  decay,"  showing  that  it  had  received  the  former 
designation, — though  by  whom  we  have  not  been  able  to  ascer- 
tain,— since  the  period  in  which  Hunter's  work  was  published. 
He  states,  in  opposition  to  Hunter,  that  the  disease  originates 
from  within  the  tooth,  i.  e.,  "the  bony  part  of  the  crown  of  the 
tooth,"  and  "that  when  it  has  made  some  progress  internallj',  a 
small  opaque  spot  appears  on  the  enamel,"  etc.  "The  proximate 
cause  of  caries  appears  to  be  an  inflammation  in  the  bone  of  the 
crown  of  the  tooth,  which,  on  account  of  its  peculiar  structure, 
terminates  in  mortification."  Again,  the  cause  of  the  mortifica- 
tion in  the  bone  of  the  tooth  is  inflammation  occurring  to  the 
dental  pulp,  "occasioned  by  any  excitement  that  produces 
irregular  action,"  and  which,  "  when  inflamed,  separates  from 
the  bone,  and  the  death  of  the  tooth  is  the  consequence,"  in  the 
like  manner  "  that  a  caries  of  other  bones  is  caused  by  a  sepa- 
ration of  those  membranes  which  cover  them  and  which  are 
attached  to  them." 

It  is  evident,  from  what  is  stated  above,  that  Fox  attempted 
to  show  the  similarity  of  dental  caries  to  that  disease  in  bone, 
adopting  the  theories  respecting  the  latter  prevalent  in  his  day. 

The  next  writer  of  eminence  is  Thomas  Bell,^  whose  work 
ap[)eared  about  thirty  years  after  the  last-named,  and  whose 
views  do  not  so  very  materially  difl:er  from  his.  During  the 
period  just  mentioned  more  correct  views  had  come  to  be  enter- 
tained in  regard  to  diseases  in  bone  generally,  the  structure  of 

'  The  Natural  History  of  the  Human  Teeth,  by  John  Hunter. 
2  Tlie  Natural  History  and  Diseases  of  the  Human  Teeth,  by  Joseph  Fox. 
*  Tlie  Anatomy,  Physiology,  and  Diseases  of  the  Teeth,  by  Thomas  Bell, 
F.Il.C.S.,  etc. 


DENTAL    CARIES.  123 

that  tissue  being;  better  understood.  Bell  commences  bj  severe 
strictures  on  the  name  "  caiies,"  which  he  considers  "  is  totally 
misapplied,"  and  desires  to  substitute  for  it  "gangrene  of  the 
teetli,"  "as  the  disease  has  not  the  slightest  analogy  to  true 
caries  in  bone."  "Its  proximate  cause  is  inflammation  in  the 
bony  structure  of  the  tooth,  set  up  by  cold  or  any  other  cause, 
and  the  part  which  suffers  the  most  severely  is  unable,  from  its 
possessing  comi)aratively  but  a  small  degree  of  vital  power,  to 
recover  from  the  effects  of  the  inflammation,  and  mortification 
of  that  part  is  the  consequence."  Roots  that  have  lost  their 
vitality,  owing  to  the  destruction  of  the  pulp,  "  are  no  longer  the 
subject  of  disease,  and  often  continue  for  years  in  nearly  the 
same  apparent  state." 

Robertson,  of  Birmingham,  in  a  work  almost  exclusively 
devoted  to  this  subject,  and  published  in  1835,'  adopts  a  wholly 
different  view  from  either  of  the  foregoing,  believing  the  disease 
to  be  essentially  the  result  of  a  chemical  action  U[ion  the  teeth. 
"  The  only  cause  capable  of  explaining  the  partial  operation  and 
the  particular  situations  of  decay  is  the  corrosive  or  chemical 
action  of  the  solid  particles  of  food  which  have  been  retained 
and  have  undergone  a  process  of  putrefaction,  or  fermentation, 
in  the  several  parts  of  the  teeth  best  adapted  for  their  reception," 

At  the  time  when  Robertson  wrote,  the  true  structure  of  den- 
tine was  but  little  understood ;  he  held  that  the  sole  object  of 
the  pulp  was  to  supply'  additional  bone  to  the  tooth  when  worn 
by  mastication  ;  but,  if  so,  why  a  pulp-cavity  at  all?  Even  wiien 
the  researches  of  J.  Tomes  with  regard  to  the  contents  of  the 
dentinal  tubuli  had  been  made  known,  this  writer  still  held  that 
the  office  of  the  pulp  or  bloodvessels  was  not  to  supply'  nutriment 
to  the  bone  of  the  tooth,  but  for  the  object  above  mentioned;^ 
but  then  he  avows  himself  a  disbeliever  in  the  value  of  micro- 
scopic research  in  throwing  light  upon  either  the  cause  or  the 
nature  of  dental  caries. 

John  Tomes,^  w^hose  opinions  have  generally  received  the 
appellation  of  the  Chemico-Vital  Theory  of  Dental  Caries,  and 

'  A  Practical  Treatise  on  the  Disease;;  of  the  Teeth,  in  which  the  Origin  and 
Nature  of  Decay  are  Exphiined,  etc.,  b}'  William  Robertson. 

2  Trans.  Odont.  Soc,  vol.  i.  p.  101. 

'  A  Course  of  Lectures  on  Dental  Physiology  and  Surgery,  by  John  Tomes, 
1848. 


124        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGy. 

are  a  happy  combination  of  the  two  very  opposite  views  which 
had  been  advanced,  believes  that  it  "  may  be  defined  as  the  death 
and  subsequent  progressive  decomposition  of  a  part  or  a  whole 
of  the  tooth  ;"  that  with  the  loss  of  its  vitality  the  dentine  loses 
also  its  power  of  resisting  chemical  action,  and  tliat  consequently 
the  dead  part  is,  under  favoring  circumstances,  decomposed  by 
the  fluids  of  tlie  niouth;  "that  there  njust  be  a  concurrence  of 
dead  dental  tissue  and  of  a  condition  of  the  oral  fluids  capable 
of  decomposing  the  dead  [lart  before  the  phenomena  of  caries  can 
be  developed;"  that  in  the  course  of  its  progress  there  are  dis- 
tinct evidences  of  vital  action,  to  wit,  the  transparent  zone,  the 
formation  of  secondary  dentine  in  the  pulp,  and  the  occurrence 
of  pain  in  a  tooth  often  long  before  the  disease  has  encroached 
upon  the  pulp-cavit}'.  The  manner  in  which  the  decomposition 
of  the  dead  dentine  is  brought  about  is  by  the  chemical  solution 
of  its  earthy  ingredients,  the  solvents  being  probably  furnished 
by  the  saliva  in  abnormal  condition,  especially  when  containing 
excess  of  acid  mucus.  It  is  also  suggested  in  a  note  that  the 
decomposition  of  the  gelatine  may  furnish  an  acid  of  sufiicient 
strength  to  rob  the  contiguous  dentine  of  its  lime.  The  pre- 
disposing causes  of  dental  caries  have  for  the  most  part  a  struc- 
tural origin,  they  are  faults  in  the  development  of  the  dental 
tissues,  and  especially  of  the  enamel :  such  are  the  pits  in  honey- 
combed teeth,  abnormal  depth  in  the  fissures  on  the  masticating 
surfaces  of  teeth,  imperfections  in  the  enamel  fibres  themselves, 
and  imperfections  in  their  union  with  each  other,  and  in  the 
dentine  an  imperfect  calcification  of  that  structure.  Fevers,  a 
scrofulous  diathesis,  salivation,  indigestion,  a  low  damp  situation, 
are  amongst  the  general  predisposing  causes.  "Circumstances 
which  favor  the  chemical  decomposition  of  the  dental  tissues 
may  lead  also  to  the  loss  of  vitality  which  renders  them  sus- 
ceptible of  decomposition.  Thus  caries  may,  no  doubt,  be  ex- 
cited by  the  local  application  of  numerous  substances,  such  as 
the  mineral  acids,  either  when  incautiously  taken  in  medicine 
or  in  sweetmeats,  and  also  by  the  presence  of  the  gastric  acids 
eructated  during  a  fit  of  indigestion." 

In  a  later  work'  than  that  from  which  we  have  quoted,  the 
same  views  are  maintained,  though  more  stress  is  laid  upon  the 

'  A  System  of  Dental  Surgery,  by  John  Tomes,  F.R.S.,  1859. 


DENTAL    CARIES.  125 

influence  of  acid  mucus  in  the  process;  hut  the  saliva  or  even 
the  stomach  may  supply  the  necessary  acid  hy  whicii  the  vitality 
of  the  part  is  destroyed  and  decomposition  succeeds  the  loss  of 
life. 

In  the  latest  work  of  this  author,  edited  also  hy  his  son, 
C.  S.  Tomes,'  the  leaning  is  evidently  towards  the  views  of 
Rohertson,  which  have  recently  received  some  confirmation  at 
the  hands  of  Masjitot,  Leher  and  Rottenstein,  and  Wedl,  all  of 
whom  more  or  less  avow  that  the  conditions  observed  in  carious 
teeth  are  to  be  met  with  in  human  teeth  and  hippopotamus 
ivory  which  have  been  emploj^ed  as  artificial  substitutes  in  the 
mouth.  Thus,  accordini^  to  this  author,  "there  is  an  over- 
whelming body  of  evidence  to  show  that  caries — in  so  far  as  it 
is  a  process  of  disintegration — has  no  relation  whatever  to  the 
connection  of  the  teeth  with  the  living  body."  The  translucent 
zone  of  the  earlier  works  is  in  this  no  longer  an  evidence  of 
a  vital  action  occurring  in  the  progress  of  the  disease,  but  a 
result  of  chemical  decomposition  of  the  dentine,  as  adduced  by 
Wedl  and  Leber  and  Rottenstein,  but  in  opposition  to  Magitot 
and  Salter.  Finally,  the  conclusion  is,  "  that,  inasmuch  as  no 
characteristic  appearances  can  be  found  to  distinguish  caries  as 
occurring  in  living  from  that  attacking  dead  teeth,  it  seems 
that  the  hypothesis  of  vital  action  in  any  way  modifying  the 
disease  must  be  abandoned  in  (olo,  and  dental  caries  cannot, 
strictly  speaking,  be  said  to  have  any  '  pathology.'  " 

Bridgman,  who  "^vas  the  successful  candidate  for  a  prize  essay 
on  dental  caries,^  attributes  the  phenomena  witnessed  in  that 
.  disease  to  purely  electrical  conditions.  He  compares  the  mouth 
to  an  electrolytic  apparatus,  in  which  the  crowns  of  the  teeth 
represent  under  ordinary  conditions  the  positive  electrodes, 
whilst  their  roots,  with  the  cutis,  etc.,  represent  the  negative 
electrodes,  the  saliva  of  course  being  the  electrolyte.  When 
certain  abnormal  conditions  in  the  saliva  or  vascular  system 
exist,  then  electrical  action  is  set  up  with  such  intensity  that 
the  positive  pole,  the  crown  of  a  tooth,  yields  up  its  lime  salts, 
which  pass  to  the  negative  pole  represented  by  the  root,  where 

>  A  System  of  Dental  Surgery,  by  John  Tomes,   F.R.S.,  etc.,   and  C.   S. 
Tomes,  M.A.     1873. 
"  Tiaus.  Odont.  Soc,  vol   iii.  p.  369. 


126    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

they  are  at  times  deposited  as  tartar.  It  is  impossible  in  a 
short  statement  to  do  justice  to  a  theory  which,  although  at 
variance  with  certain  facts  as  we  now  know  them  to  exist,  is 
nevertheless  maintained  by  much  ingenious  argument. 

Spence  Bate,  of  Plymouth,  attributes  dental  caries^  chiefly  to 
the  presence  of  carbonic  acid  in  abnormal  positions  and  in 
abnormal  quantities.  A  death  and  decomposition  of  the  mem- 
brane covering  the  enamel  will  furnish  this  acid  in  a  nascent 
state,  in  which  condition  it  will  act  readily  upon  the  lime-salts 
of  the  subjacent  structure,  especially  if  tliat  structure  be  imper- 
fectly developed.  When  the  disease  has  reached  the  dentine, 
the  dentinal  tubuli  become  opened,  and  empty  tlieir  contents 
into  the  carious  cavity,  wliich  likewise  decomposing  furnish 
further  sui>plies  of  nascent  carbonic  acid  to  continue  and  aug- 
ment the  process. 

Finally,  Leber  and  E-ottenstein^  advocate  the  view  that  the 
disease  in  question  is  mainly  due  to  the  presence  of  the  lep- 
tothrix.  As  this  cryptogamic  growth  is  not  met  with  in  the 
earlier  stages  of  caries,  when  confined  to  the  enamel  only,  they 
apprehend  that  portion  of  the  process  to  be  due  to  the  solvent 
action  of  an  acid  ;  but,  when  the  subjacent  dentine  becomes  ex- 
posed, then  the  leptothrix,  finding  its  w^ay  into  the  dentinal 
canals,  etiects  a  rapid  disintegration  of  the  dentine. 

Of  the  various  opinions  advanced,  that  which  most  accords 
with  our  own  views  is  the  so-called  chemieo-vital  theory  of  J. 
Tomes,  notwithstanding  that,  as  stated  in  the  last  edition  of 
his  work,  the  editors  have  followed  the  opinions  of  certain  Con- 
tinental writers,  who,  judging  from  the  comparison  of  micro- 
scopical preparations  obtained  from  carious  teeth,  and  teeth 
softened  and  acted  upon  by  food  and  oral  fluids  when  attached 
to  artificial  dentures,  have  adopted  ap[)arently  the  purely  chemi- 
cal theory  of  Robertson.  Tiiat  the  conditions  prevailing  in  the 
progress  of  dental  caries  are  dissimilar  to  those  which  take  place 
in  the  inflan)mation  of  most  soft  structures,  which  are  hyper- 
femia,  ettusion,  cell-migration,  softening,  fatty  degeneration, 
etc.  etc.,  we  can  readily  admit,  without  denying  to  the  process  a 
pathological  character. 

'  The  Piithology  of  Dental  Caries,  by  C.  Spence  Bate,  F.R.S.,  Trans.  Odont. 
Soc.,  vol.  iv.  p.  40. 
2  Kecherches  sur  la  Carie  Dentaire,  par  Leber  et  Roltenstein,  Paris,  18G8. 


DENTAL    CARIES.  127 

The  teeth  of  every  person  must  in  the  mouth,  like  every 
other  portion  of  the  body — the  hair,  nails,  and  skin  included — 
be  continually  exposed  to  conditions,  which,  but  for  a  i)revailing 
something,  would  ere  long  subject  them  to  those  chauges  which 
all  highly  com[)lex  nitrogenous  bodies  undergo  when  removed 
from  its  s[ihere  or  influence.  It  is  this  jirevailing  something, 
ceasing  or  changing  with  the  loss  of  life  in  an  individual, 
that  immediately  permits  the  existence  of  those  affinities,  or  no 
longer  opposes  their  action,  which  tend  to  break  u[)  into  simpler 
forms  the  more  complex  chemical  com})Ounds  of  which  an 
animal  or  vegetable  body  consists,  and  to  which  consequently 
we  apply  the  vague  term  "  vital  force,"  which,  if  actually  a 
force,  is  probably  not  more  distinct  from  the  chemical  than  the 
latter  is  from  the  electrical,  or  any  of  the  so-called  forces ; 
indeed,  it  may  be  only  one  manifestation  of  the  chemical  force. 
Whilst  this  exists  or  remains  unchanged,  the  teeth  are,  so  to 
speak,  protected  from  conditions,  viz.,  moisture,  warmth,  action 
of  acids,  and  bodies  themselves  undergoing  change  and  decom- 
position, which  Avould  otherwise  certainly  allow  the  exercise 
which  those  affinities  are  ever  exerting  to  break  up  complex 
organic  compounds. 

We  are  prepared  to  grant  that  such  affinities  may  when 
strong  overcome  that  resistance,  as  well  as  have  their  full  action 
when  it  is  weakened,  changed,  or  withdrawn,  but  this  would  in 
our  eyes  constitute  it  a  pathological  process.^  If  we  follow  its 
course  as  we  have  described  it,  we  shall  find,  as  a  rule,  that 
the  disease  continues   to   be  more  circumscribed   and    limited 

1  That  the  microscopical  appearances  as  exhibited  in  the  decay  that  occurs 
in  teeth  employed  as  artificial  substitutes  should  closely  resemble  the  same  in 
teeth  naturally  attached  in  the  mouth  is  rather  what  we  should  look  for,  and, 
to  our  mind,  is  no  evidence  that  the  process  is  not  a  patliological  one,  both 
having  been  brought  into  the  same  or  nearly  similar  condition  by  pathological 
processes  ;  tiie  former  by  probably  tlie  death  of  the  whole  individual  of  whom 
the  tooth  formed  a  part,  the  latter  by  the  death  of  the  portion  of  the  tooth 
attacked,  the  conditions  of  the  subsequent  decomposition  being  almost  precisely 
the  same.  If  we  are  bound  to  assert  that  the  loss  of  vitality  in  the  dentine  of 
a  living  tooth  is  a  result  of  inflammatory  action,  then  we  must  admit  that  our 
evidences  of  its  existence  are  very  small ;  recent  research  would  rather  tend  to 
show  that  it  might  be  so,  and,  in  the  case  of  affected  cementum,  there  is  every 
ground  for  believing  it  to  be  so  ;  but  the  loss  of  vitality  in  a  part  may  occur 
independently  of  iiitlammator}'  action,  and  yet,  we  presume,  deserve  the  ap- 
pellation of  pathological. 


128    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

SO  long  as  the  pulp  retains  its  vitality;  with  the  loss  of  vitality 
a  much  more  general  softening  of  the  surrounding  dentine 
ensues,  which  is  more  comparable  to  tliat  of  natural  teeth 
attached  to  artiticial  dentures.  Our  views,  which  on  the  whole 
differ  but  little  from  those  of  J.  Tomes,  are  that  the  disease 
arises  from  the  action  of  particles  of  food,  or  mucus,  or  the  com- 
bination of  both,  undergoing  decomposition  in  contact  with  the 
teeth  at  parts  where,  owing  to  certain  conditions,  that  influence 
which  protects  living  structures  is  weakened  or  absent.  The 
favoring  conditions  will  be  imperfection  in  development,  either 
in  the  structure  itself,  or  in  the  form  of  the  teeth,  whereby  a 
greater  opportunity  for  the  lodgment  and  retention  of  food 
and  mucus  is  afforded.  This  latter  alone,  we  are  ])repared  to 
admit,  may  in  time  be  al)le  to  overcome  the  resisting  force 
where  otherwise  the  development  may  not  be  imperfect.  To 
the  acids  formed  in  such  decomposition  of  food  and  mucus  has 
been  generally  assigned  the  entire  agency  in  the  work;  but, 
whilst  admitting  the  great  importance  of  the  part  they  piny,  we 
cannot  but  believe  that  another  condition  is  largely  concerned 
in  it,  viz.,  that  arising  from  the  contact  of  bodies  undergoing 
molecular  change  u[)on  bodies  in  a  stable  condition.  This,  tliough 
no  longer  allowed  to  be  the  potential  agency  in  fermentation,  is 
still  admitted  to  exist  in  the  case  of  bodies  in  a  state  of  putrefac- 
tion. Fermentation,  in  which  the  leptothrix  may  play  no  un- 
important part,  probably  does  take  pl^ce  to  some  extent  in  the 
food  collected  in  a  carious  cavity,  and  may  produce  the  acids 
which  certainly  assist  in  the  process.  Experiments  which  we 
made  some  years  ago,^  where  carious  teeth,  from  which  all 
softened  dentine  had  been  removed,  were  exposed  to  the  action 
of  different  kinds  of  food  contained  in  loosely  covered  vessels, 
and  mixed  some  with  water  and  some  with  water  and  saliva, 
and  kept  at  about  100°  F.  for  twenty  days,  showed  that  the 
greatest  amount  of  change  was  not  always  in  proportion  to  the 
greatest  amount  of  acid  geneiated,  or  even  to  the  character  of 
the  acid.  Ordinary  baker's  bread  in  a  solution  of  water  and 
saliva  was  the  most  active,  although  the  solution  was  far  less 
rich  in  those  acids  which  are  known  to  decompose  most  readily 
the  pliosphates  of  lime  than  was  the  case  in  a  similar  experi- 

'  "On  tlie  Nature  of  Dental  Caries,"  Trans.  Odont.  Soc,  vol.  iii.  p.  80. 


DENTAL    CARIES.  129 

ment  with  cane-sugar,  water,  and  saliva.  The  appearance,  too, 
of  the  softened  dentine  in  the  bread  and  saliva  experiment  cer- 
tainly more  closely  resembled  that  obtained  from  a  carious  tooth 
than  in  any  other.  In  the  case  of  teeth  exposed  under  the  same 
conditions  in  vessels  including;  meat  and  water,  and  meat,  water, 
and  saliva,  no  softening  whatever  took  place,  but  it  must  be 
admitted  that  the  liquids  at  the  end  of  the  experiment  were 
strongly  alkaline. 

[This  starchy  deposit  of  the  remainder  of  bread  or  biscuit  or 
cracker,  which  hangs  like  a  sour  pulp  or  paste  around  or  at 
the  necks  of  the  teeth,  is  apparently  the  active  cause  in  many 
mouths  of  labial  or  buccal  surface  decay ;  for  teeth  that  are  freed 
from  this,  by  their  shape  or  the  movements  of  the  soft  tissues 
over  them,  will  escape,  while  those  where  lodgment  is  allowed, 
in  the  same  mouths,  afford  notable  examples  of  the  ravages  of 
the  disease.] 

In  considering  the  question  before  us,  we  have  laid  no  stress 
upon  the  existence  of  the  zone  of  Tomes  as  evidencing  a  vital 
action  iu  the  process,  its  nature  having  been  disputed  by  high 
authorities ;  but,  putting  aside  this  phenomenon,  we  may  cer- 
tainly see  in  those  cases  where  very  superficial  caries  has  existed 
and  become  arrested,  as  frequently  witnessed  upon  the  coronal 
surfaces  of  tirst  molars,  a  hardening,  which,  as  compared  with 
the  subjacent  structure,  can,  we  think,  hardly  be  explained  as 
wholly  the  result  of  friction  and  polishing.  Here  we  must 
leave  the  subject,  and  with  the  same  remark  as  when  we  entered 
upon  it,  viz.,  that  no  explanation  of  the  causes  or  nature  of 
dental  caries  has  yet  been  offered  which  has  been  generally 
acceptable  to  dental  practitioners. 

The  question  may  now  be  considered — is  the  disease  which 
we  have  been  describing,  and  which  presents  at  times  different 
features,  one  disease,  or  may  we  be  comprehending  in  our  de- 
scription more  than  one?  Some  authorities  incline  to  the  latter 
view,  and  divide  dental  caries  into  soft  and  white  decay,  and 
hard  and  dark  decay,  in  which  latter  condition  the  structures 
affected  are  at  times  almost  black.  Most  authorities,  however, 
are  agreed  that  the  disease  is  precisely  the  same,  the  conditions 
being  varied  by  the  former  being  rapidly,  the  latter  slowl}', 
progressive.  A  variety  of  caries  termed  chalky,  and  met  with 
most  frequently  in  the  third  molars  esjiecially  of  the  upper 
9 


130    MAXnAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

jaw,  would,  from  the  appearance  which  the  affected  portion 
presents,  give  the  idea  that  its  disintegration  had  not  been  pre- 
ceded by  a  solution  and  removal  of  the  lime-salts,  but  that  the 
calcified  structure  had  itself  broken  down.  If  we  take  some 
of  the  chalky  powder,  which  upon  the  finger-nail  appears  to 
resemble  whitning,  and  examine  it  under  the  microscope,  we 
shall  find  it  to  consist  of  fragments  of  dentinal  tubuli  and  inter- 
tubular  substance  (see  Fig.  88),  in  which  the  tobacco-pipe  ap- 
pearance noticed  by  J.  Tomes  is  very  conspicuous :  a  little 
hydrochloric  acid  added  to  the  specimen  liberates  abundant 
bubbles  of  gas. 

Another  condition  is  where  a  loss  of  substance  occurs  gene- 
rally at  the  necks  of  the  teeth,  giving  the  appearance  of  a  por- 
tion of  the  tooth  having  been  removed  by  a  file,  and  the  place 
highly  polished.  This  form  has  been  termed  "decay  by  denu- 
dation," or  "erosion."  It  is  most  commonly  seen  upon  the 
labial  aspects  of  the  teeth,  especially  the  bicuspids,  but  it  also 
does  occur,  though  less  frequently,  upon  their  lingual  surfaces, 
and  in  other  spots  inaccessible  to  the  tooth-brush,  which  proves 
that  it  does  not  arise  from  the  friction  of  that  appliance,  as  some 
have  supposed  :  it  is  also  stated  to  be  met  with  in  some  of  the 
lower  animals.  [It  has,  however,  frequently  been  noticed  that 
the  canines  where  prominent  seem  to  suffer  most,  and  the  left 
one  in  right-handed  people  is  generally  more 
S-  93.  deeply  grooved,  which  would  look  as  if  the 

tooth-brush  may  play  an  important,  if  only 
an  auxiliary  and  secondary,  part  in  removing 
the  partially  softened  enamel  and  dentine, 
while  it  may  also  add  to  the  irritation  that 
may  be  the  prime  cause  of  the  acid  secretion 
from  the  firum.l    It  appears,  however,  almost 

A    cnspidatns    oi    the  o  j  i.  x  ' 

lower  jaw  worn  on  its  perfectly  identical  in  appearance  with  the 
lingual  surface  by  the     ^.g^,,^^  ^way  of  a  tooth  at  its  neck  by  the 

friction  of  a  plate.  a  J  •/ 

friction  of  a  clasp  to  support  a  denture  ;  such 
clasps  invariably  retain  small  portions  of  food,  bread-substance 
especially,  so  that  tiie  rapid  loss  of  substance  they  occasion  is 
probabl}'  something  more  than  friction.  It  is  stated  to  be  more 
common  to  the  upper  than  to  the  lower  teeth,  and  we  believe 
this  to  be  correct.  Although  most  frequently  met  with  at  or 
below  the  termination  of  the  enamel  at  the  neck  of  the  tooth, 


DENTAL    CARIES.  131 

it  occasionally,  i.  e.,  on  the  assumption  that  it  is  the  same  affec- 
tion, attacks  the  enamel  itself.  We  have  cases  on  record  where 
the  two  upper  central  incisors  have  so  suffered,  and  in  persons 
of  undoubtedly  good  constitutions.  In  one  case,  which  we  had 
under  observation  for  more  than  twelve  years,  the  disease  had 
appeared  on  the  labial  surface  of  the  enamel,  midway  between 
the  cutting  surface  of  the  tooth  and  the  gum.  As  it  progressed, 
there  was  no  discoloration,  and  the  surface  presented  was  highly 
polished,  and  intensely  hard  and  sensitive.  [In  a  number  of 
cases  of  this  kind,  treated  by  cutting  retaining  grooves  and  fill- 
ino-  with  srold,  there  seemed  relief  sufficient  to  warrant  its  recom- 
mendation  in  almost  every  case  that  has  progressed  to  a  depth 
much  below  the  enamel.]  Eventually  one  of  the  teeth  broke 
off,  the  pulp  having  become  dentinified  in  the  progress  of  the 
disease;  the  other  has  remained  in  much  the  same  condition 
for  a  number  of  years,  the  patient,  a  lady,  aged  now  about 
thirty-five,  having  most  assiduously  kept  the  cavity  sealed  with 
white  wax,  which  almost  completely  hides  the  deformity.  We 
feel  inclined  to  attribute  the  condition  which  we  have  described 
to  the  solvent  action  of  an  acid  secreted  by  certain  labial  and 
other  mucous  glands.  It  is  by  no  means  uncommon  for  dental 
caries  in  its  ordinary  form  to  appear  upon  the  eroded  portions 
of  the  necks  of  teeth,  when  the  difference  in  the  two  conditions 
is  very  manifest.  Cases  are  recorded  where  the  teeth  generally, 
but  especially  the  six  upper  front  ones,  have  undergone  a  gene- 
ral loss  of  substance  above  the  gum  ;  such  loss  has  been  too 
general  to  be  accounted  for  in  any  other  way  than  that  they 
have  been  attacked  by  some  solvent  which  has  acted  upon  them 
generally.  [Pressure,  if  continued,  upon  the  soft  tissues  will 
produce  absorption,  and  even  the  bony  structure  will  after  a 
time  yield  to  the  same  cause.] 

Allusion  has  been  made  to  the  greater  frequency  of  dental 
caries  in  the  present  day  than  formerly,  and  we  may  probably 
investigate  this  question  more  profitably,  and  with  more  hope 
of  a  satisfactory  solution,  than  the  former  one,  viz.,  its  patho- 
logy. One  of  the  chief  causes  of  this  degeneracy  we  believe  to  be 
the  change,  both  in  character  and  mode  of  preparation,  which 
the  food  of  man  has  undergone  during  the  last  few  centuries. 
Take,  for  instance,  his  bread ;  this,  as  compared  with  that  of 
the  present  day,  was  imperfectly  ground  and  contained  a  larger 


132   MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

proportion  of  husk  of  the  grain,  and,  in  consequence,  a  larger 
proportion  of  phosphates.  Baked  into  a  hard  mass,  it  required 
no  small  amount  of  force  to  bite  and  reduce  it  to  a  pulp  Avith 
the  saliva;  yet  this  was  readilj''  accomplished  by  the  well- 
developed  javva  and  strong  teeth  of  bygone  ages.  His  meat, 
cooked  soon  after  the  death  of  the  animal  that  provided  it,  was 
presented  to  him  in  a  condition  which  would  sorely  tax  both 
teeth  and  jaws  of  the  present  generation :  it  was  not  then  the 
custom  to  hang  meat  until  upon  the  eve  of  putrefaction,  or 
render  it  so  soft  by  culinary  art  that  it  can  be  almost  sucked  into 
division,  rather  than  brought  to  that  state  by  laceration  and 
pounding.  But  further  than  this  condition  of  his  food,  let  us 
remark  his  manner  of  devouring  it.  The  meat  was  torn  from 
the  bone  by  the  grasp  of  the  incisors  and  cuspidati,  whilst  in 
the  present  day  by  appliances  indispensable  in  civilized  life, 
the  knife  and  fork,^  the  office  of  those  teeth  has  become  almost 
a  sinecure.  Organs  or  structures  not  properly  exercised  undergo, 
after,  it  maj'  be,  many  generations,  some  form  of  degeneration, 
and  it  is  only  reasonable  to  conclude  that  the  teeth  and  jaws 
follow  that  same  law ;  the  former  unprotected,  losing  their 
power  of  resisting  external  agencies  ;  the  latter  protected,  appear- 
ing in  diminished  size  and  incapable  of  aftbrding  capacious  den- 
tal arches,  and  hence  also  results  a  crowding  of  the  teeth  with 
pressure,  which  is  an  acknowledged  predisposer  to  caries.  The 
evidence  of  the  injurious  effects  of  soft  food  upon  the  teeth  of 
dogs  is  strong  su[)port  of  the  foregoing  conclusion. 

Another  result  arising  from  too  soft  a  food  is  the  unhealthy 
condition  of  the  gums.  From  loss  of  a  natural  stimulus  they 
become  hy[)erpemic,  soft,  and  spongy,  not  only  causing,  by 
absorption  of  the  alveoli,  premature  shedding  of  the  teeth,  but 
secreting  an  abnormal  quantity  of  acid-forming  mucus.  To  the 
above  must  be  added  all  conditions  unfavorable  to  the  perfect 
development  and  health  of  the  body  ;  the  preservation  of  the 
weak  and  feeble,  such  as  in  a  less  civilized  state  would  never 
attain  to  manhood,  and  consequent  matrimony  with  progeny  ; 
the  depressing  effects  due  to  over-exertion  of  mental  and  nerv- 

'  Perhaps  there  was  loss  ahsunlity  in  a  bishop  in  tlie  reign  of  Queen  Eliza- 
beth preaching  a  sermon  against  the  use  of  the  fork,  than  has  been  commonly 
attributed  to  him  in  our  time. 


DENTAL    CARIES.  133 

ous  energies;  and  the  far  too  great  indulgence  in  the  luxuries 
of  the  table,  especially  stimulants,'  which  weaken  the  digestive 
organs  and  vitiate  the  saliva.  The  mixing  of  breed  also 
appears  to  have  an  unfavorable  influence  generally  upon  the 
physique  of  a  nation,  and  especially  upon  their  teeth.  The 
effects  of  administering  medicines,  especially  acid  ones,  have  by 
some  been  considered  important  factors  in  producing  dental 
caries.  We  believe  that  it  has  been  overrated  ;  at  the  same 
time,  the  long  continuance  of  acid  medicines  renders  such  secre- 
tions as  the  saliva  abnormally  acid  ;  and  the  direct  contact  of 
such  acids  as  phosphoric,  hydrochloric,  and  nitric  may  no  doubt 
in  time  affect  the  teeth,  as  they  certainly  do  certain  kinds  of 
metallic  fillings  in  them.  As  sulphuric  acid  has  but  a  very 
slight  action  upon  the  dental  tissues,  from  the  circumstance 
that  an  insoluble  sulphate  of  lime  is  formed  as  soon  as  it  touches 
them,  it  may  well  be,  where  possible,  substituted  for  any  of  the 
former.  The  common  practice  of  employing  a  tube  when  taking 
acid  medicines  is  of  but  small  advantage  compared  with  a 
thorough  rinsing  of  the  mouth  with  a  solution  of  bicarbonate 
of  potash  or  soda  afterwards. 

'  Amongst  the  various  classes  of  mankind  whose  teeth  we  have  had  the 
opportunity  of  inspecting,  few  have  surpassed  in  beauty  those  of  the  Bedouin 
of  the  Arabian  desert ;  and  their  much  greater  freedom  from  caries,  as  com- 
pared with  the  Arab  of  the  town,  is,  by  "Waller  Bey,  of  Cairo,  who  is  able  to 
speak  from  large  experience,  attributed  to  the  former  being  total  abstainers 
from  alcoholic  beverages.  Their  purity  of  breed,  and  the  very  perfect  sanitary 
conditions  of  their  surroundings,  must  not,  however,  be  left  out  of  the  account. 
[The  less  the  conditions  of  natural  selection  and  survival  of  the  fittest  are 
disturbed,  the  greater  the  likelihood  of  a  healthy  race.  The  writer's  observation 
of  the  Bedouin  confirms  the  universally  received  rule,  that  under  adversities 
of  life  the  bold  and  hardy  survive,  and  beget  children  who  inherit  the 
physical  endurance  of  their  parents,  or  else,  if  delicacy  of  constitution  be  their 
lot,  death  soon  weeds  them  out.  The  law  may  be  laid  down  that  the  teeth  are 
equally  valuable  guides  as  to  savage  man's  chances  of  life  as  they  are  to  an  ani- 
mal's. It  must,  however,  be  recognized  sooner  or  later  that  children,  who  are 
reared  in  the  free  open  air  of  a  healthy  climate,  are  better  qualified  for  the  battle 
of  life  than  those  raised  under  the  enervating  influences  of  house  or  institute 
training.  Children  with  decay  running  riot  in  their  systems  have  been  so 
frequently  saved  by  a  change  to  open-air  life,  as  to  make  the  fact  no  longer 
disputable.  Dental  caries  has  so  frequently  yielded  to  a  change  from  an  in-door 
to  an  out-door  life,  that  it  must  be  admitted  that  the  Greeks  with  their  open-air 
gymnasia  understood  and  reaped  the  benefits  of  pure  air.  The  tendency  now 
is  to  a  better  ventilation  of  school-rooms,  and  even  to  open-air  sessions  during 
the  summer  season.] 


134   MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


[CHAPTER    VII. 

THE  SELECTION  OF  INSTRUMENTS.' 

The  selection  of  instruments  is  one  of  the  most  important 
duties  of  the  dental  preceptor  or  teacher,  and  the  varieties  of 
sets  recommended  by  ditierent  operators  seem  to  be  limited  only 
by  the  number  of  the  recommeuders.  For  some  years  the  set 
selected  by  the  writer,  and  about  to  be  mentioned,  has  been  the 
source  of  much  satisfaction  in  its  adaptability  to  the  various 
demands  made  upon  it,  and  is  the  standard  upon  which  or  from 
which  sets  have  been  selected  and  used  by  many  students.  The 
only  objection  has  been  as  to  its  expense,  which  at  first  sight 
may  seem  considerable,  but,  after  some  years  of  study  of  the 
peculiarities  of  dental  students,  it  may  be  safely  said  that  they 
rarely  enter  practice  with  less  than  the  amount  here  spoken  of, 
and  often  more,  much  of  which  is  after  trial  discarded  as  un- 
handy and  useless. 

In  the  first  place,  true  economy  will  be  practised  by  the  pur- 
chase of  a  case,  in  order  that  each  instrument  may  have  a  sepa- 
rate and  appropriate  place ;  for  misplacement  and  loss  will  try 
the  temper  of  the  patient,  the  operator,  and  the  instrument. 
If  thrown  loosely  together,  the  edges  are  impaired  or  destroyed 
on  each  other,  and  this,  although  not  always  understood  by  the 
young  operator,  makes  a  wonderful  ditierence  in  time  and  re- 
muneration in  practice. 

Beyond  all  else  the  points  of  the  instruments  are  to  be  con- 
sidered. As  to  the  handles,  it  is  more  a  question  of  taste;  yet 
the  balance  and  shape  have  much  to  do  with  the  dexterity  of 
the  operator. 

The  new  models  of  milled  socket  handles,  made  by  the  S.  S. 
White  Dental  Manufacturing  Company,  seem  to  answer  much 
that  is  desired  in  this  direction,  while  they  ofter  a  ready  and 

'  [Acknowledgment  is  due  to  The  S.  8.  White  Dental  Manufacturing  Co., 
for  the  courtesy  in  permitting  the  use  of  illustrations  of  a  number  of  the  instru- 
ments in  this  chapter.] 


THE    SELECTION    OF    INSTRUMENTS. 


135 


expeditious  means  for  renewing  the  points  that  may  be  broken, 
to  say  nothing  of  the  cleanliness  and  sightliness  of  the  set  when 


1 

Mi 


Fiff.  93. 


Wew  socket  handles. 


Ul 


spread  upon  a  snow-white  linen  napkin  ready  for  use.  If  clean- 
liness is  considered  next  to  godliness  by  our  patients,  they 
certainly  appreciate  it  in  anything  designed  for  use  in  their 
mouths.  There  are  always  enough  disagreeable  and  painful 
associations  connected  with  dental  offices   to  make   it  highly 


186 


MANUAL    OF    DENTAL    SURfiERY    AND    PATHOLOGY, 


desirable  that  thej  should  be,  as  far  as  possible,  relieved  of  every 
unpdeasant  feature.  The  recent  demonstrations  of  Pasteur  be- 
fore the  world's  medical  congress  show,  that  many  diseases  are 
liable  to  propagation  as  ferments  and  infusoria,  which  from 
minute  particles  will  propagate,  grow,  and  increase  to  immense 
numbers  under  conditions  favoring  their  development,  as  in  the 
inoculation  or  vaccination  from  an  infected  animal's  fluids. 
This  would  seem  to  make  an  additional  reminder  necessary  that 
anything  short  of  the  most  exacting  and  scrupulous  care  on  the 
part  of  the  dentist  or  surgeon  is  an  offence  against  the  health  of 
the  community,  that  will  be  classed  as  criminal,  and  before  many 
years, — if  not  already — it  may  be  punished  as  such. 

Fig.  94. 


student's  iDstrament  case. 


Tlje  student  will  do  well  to  provide  himself  with  a  case  like 
that  shown  (Fig.  94),  which  may  have  four  trays  for  the  instru- 
ments, or,  what  is  perhaps  better,  have  the  separate  smaller  cases 
such  as  are  made  for  the  socket  handles. 

For  the  tray  for  instruments  for  examination  of  the  mouth, 
removing  salivary  calculus,  and  finishing  fillings:  first,  obtain 
two  fine  probes  for  examination  of  cavities.  These  should  be 
soft  and  capable  of  being  bent  into  convenient  shapes  for  passing 
around  or  between  the  teeth,  and  a  little  thicker  than  heavy 
bristles. 


THE    SELECTION    OF    INSTRUMENTS. 


137 


For  scalers,  use  the  S.  S.  W.  Nos.  10  and  8  (Fig;.  95),  which 
may  be  supplemented  with  a  pair  of  the  right  and  left.     In  the 


I 
i 

i 


Fiflc.  95. 


Scalers. 


3     O 


Dr.  Forbes' 
gouge. 


Operation  of  scaling  we  can  also  be  greatly  assisted  by 
a  selection  from  tiie  ordinary  excavators ;  the  scoops 
presently  to  be  spoken  of  being  invaluable  and  almost 
universal  in  their  application  (Fig.  106). 

For  opening  cavities  and  removing  overhanging 
walls,  Dr.  Forbes'  Nos.  1  and  2,  and  Dr.  Head's  Nos. 
20,  12,  4,  are  desirable,  and  later  on  may  be  added  as 
required  !N'os.  18  and  21  of  the  latter  set. 

]N"ext  a  curved  sickle-shaped  lancet  will  be  desirable 
for  opening  abscesses,  lancing  the  gums  of  children, 
or  around  the  wisdom  or  such  other  teeth  as  have  the 


138 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY, 


Fio;.  96. 


gums  attached — generally  only  those  that  have  stood  alone  in 

the  mouth  for  some  time.  Fig.  96  represents  a  scaler  that  may 
be  sharpened  on  both  edges,  and  made  to  answer 
the  purpose. 

The  foil  carrier  and  j^lugger  combined,  Fig.  97,  the 
writer  has  made  so  curved  as  to  meet  only  at  the 
point,  in  order  to  prevent  the  possibility  of  catching 
the  mucous  membrane  of  the  lips  or  cheeks,  and 
allowing  the  attention  to  be  concentrated  on  the 
points  of  the  instrument. 

Foil  shears  will  be  useful  for  cutting  the  gold 
foil,  but  they  may  be  dispensed  with  at  first,  and 
a  pair  of  curved  scissors  (Fig.  98)  for  use  both  in 
and  out  of  the  mouth  may  be  procured. 

For  a  mouth  mirror  the  magnifying  is  to  be  pre- 
ferred, and,  in  selecting  it,  it  should  be  held  up  close 

to  the  eye,  so  that  its  image  may  be  examined  for  imperfections. 

Those  with  the  wooden    back  and    handle  (Fig.   99)  are  less 


5 
Scaler,  to  be 
sharpened    on 
both  edges  for 
ffum  lancet. 


Fig.  97. 


Combined  foil  carrier  and  plugger. 


Fis:  98. 


Curved  scissors. 


expensive  and  very  serviceable,  but  the  nickel-plated  back  and 
carefully-fitted  water-tight  mirrors  (Fig.  100)  are  the  best,  and 
probably  the  most  economical,  all  things  considered. 

The  syringe  may  be  of  glass  (Fig.  101)  or  hard  rubber;  lately 
a  pattern  of  nickel-plated  brass  has  given  much  satisfaction. 

Hickory  pivot  wood,  cotton  and  box-wood  strips,  are  useful 
for  cleansing,  wedging,  cauterizing,  and  pivoting  teeth.  Provide 
also  a  strip  of  Scotch  or  Ilindostan  stone,  celluloid  polishing 
strips,  a  box  of  pulverized  pumice,  and  one  of  peroxide  of  tin. 


THE    SELECTION    OF    INSTRUMENTS.  139 

Fis.  99.  Fig.  100.  Fig.  101. 


Magnifying  mouth  mirrors. 


Glass  syringe. 


140        xMANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 


Dr.  Louis  Jack's  enamel  chisels. 


Fis.  103. 


^'' 


,^ 


Prof.  D.  D.  Smitli'H  plug  finisher. 


I|ie' 


Dental  files. 


THE  SELECTION  OF  INSTRUMENTS. 


141 


Dr.  Jack's  chisels  (Fig.  102)  are  often  put  into  this  tray  as 
convenient  for  opening  cavities  and  for  cutting  separations 
between  the  proximal  surfaces  of  the  teeth.  The  writer  has  his 
made  with  a  heavier  handle  and  single  point,  as  he  believes 
they  are  less  ruil)le  to  be  injured  by  a  fall. 

For  plug  finishing,  the  various  bur  drills  may  be  used,  par- 
ticularly when  the  student  has  a  dental  engine.  Ey  some, 
however,  the  hand  cutting  is  preferred  ;  or,  as  is  generally 
recommended,  the  student  may  learn  without  the  engine,  and 
after  acquiring  the  necessary  strength  and  dexterity  of  the  hand 
the  engine  may  be  employed.  Files,  Nos.  14,  19,  20,  and  33, 
together  with  Prof.  D.  J).  Smith's  plug  finishers,  iN'os.  4  and  5, 
will  be  of  value. 

A  Kseber  saw  frame.  Fig.  105,  for  carrying  watchmakers' 
fine  saws,  will   be  handy  in  starting  an  opening  between  the 


Fiij.  105. 


Kseber  saw  frame. 


teeth,  where  permanent  separation  is  desired.  The  passage  of 
the  saw  first  between  the  teeth,  will  make  the  use  of  the  tile  or 
disk  much  less  unpleasant  and  laborious  to  both  patient  and 
operator. 

The  second  tray  may  contain  the  excavators  proper;  and  here, 
as  in  all  dental  instruments,  the  shapes  that  resemble  the  human 
hand  should  be  the  most  highly  prized. 

Foremost  in  the  rank — the  very  poetry  of  points  in  steel — 
stands  a  set  of  six  finger-shaped  instruments,  devised  by  Dr. 
Corydon  Palmer.  Unfortunately  they  cannot  be  recommended 
to  every  tyro,  any  more  than  a  genuine  Cremona  violin  should 
be  placed  in  the  hands  of  a  sawyer.  But  for  the  light  and 
skilled  hand  of  the  maestro,  to  have  once  made  their  acquaint- 
ance is  to  be  ever  thankful  with  and  unhappy  without  them. 
To  a  child  who  knows  the  principles  of  digging  sand  holes 


142   MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

these  instruments  will  show  their  adaptation.  All  that  is  neces- 
sary is  to  remember  that  the  cutting  edge  is  the  linger  nail 
and  the  instrument  the  finger.  A  wood-cut  will  not  convey 
the  idea,  and,  therefore,  attempts  to  illustrate  them  have  not 
been  made. 

Next  will  follow  the  regular  scoops,  which  resemble  the  open 
hand,  and  are  nearly  as  universal  in  their  application.  They 
should  be  made  with  the  palmar  side  flat  instead  of  hollowed, 
as  the  latter  shape  weakens  the  edges  for  cutting  the  more  solid 
portions  of  the  teeth,  and  particularly  for  cutting  down  over- 
hanging walls  of  enamel — a  use  for  which  they  are  well  calcu- 
lated.   Fig.  106,  ISTos.  67  and  68,  are  the  most  useful,  but  larger 


Fiff.  106. 


^     ^      ff    ^ 


Scoops. 


sizes  may  he  required,  and  as  they  are  worn  down  in  sharpening 
they  will  approach  these  favorite  numbers.  Some  curved,  as  the 
last  four,  for  rights  and  lefts,  may  be  likened  to  the  hand,  arm, 
and  elbow  ;  they  are  useful  to  reach  down  between  teeth  upon 
the  floors  of  the  approximal  surface  cavities,  cutting  that 
portion  near  the  necks  of  the  teeth,  the  sides  may  best  be 
finished  by  the  plain  scoops  or  hoes.  They  may  be  used  also 
upon  the  mesial  walls  of  molar  crown  cavities. 

For  hatchets,  there  may  likewise  be  no  ex[)lanation  of  their 
use  required,  beyond  the  reminder  that  there  is  great  tempta- 
tion to  cut  with  them  in  lines  parallel  to  the  dentinal  tubuli ; 
a  thing  to  be  avoided,  except  where  the  tooth-substance  is  dead 
or  its  connection  with  the  pulp  cavity  severed.     The  first  two. 


THE    SELECTION    OP    INSTRUMENTS. 


143 


Nos.  14  and  16,  may  be  well  recommended,  of  the  others  it  may 
be  said  that  they  are  ottered  as  guides  to  select  from. 


Fiff.  107. 


(       -.- 


"^      1l      1l 


n 


Tl   "11 


Hi)         ijO 
Hatchets. 


Of  hoes,  no  description  as  to  the  method  of  their  use  will  be 
required.  The  first,  ISTo.  27,  is  the  one  that  should  be  provided 
at  the  outset,  and  of  the  others  the  same  may  be  said  as  above 
of  hatchets. 


Fi?.  108. 


Fisr.  109. 


27 


60       a^  58        57 

IMunioud-shaped  poiuts. 


The  diamotid-shaped  points,  Fig.  109,  ISTos.  58,  60,  59,  57,  are 
gradually  going  out  of  use  since  the  introduction  of  the  engine 
points.  They  are,  however,  very  useful  in  opening  cavities, 
particularly  upon  the  deeply-fissured  crowns  of  molars. 

With  the  above  we  may  fill  another  tray,  or,  by  selection  and 


144   MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

combining  with  the  next,  they,  with  part  of  the  following,  may 
be  put  into  one  tray. 

In  the  full  set  of  instruments  the  third  tray  is  devoted  almost 
exclusively  to  drills,  which  are  used,  generally,  in  the  last  step 
of  excavation — namely,  shaping,  smoothing,  and  surfacing — - 
while  in  the  formation  of  retaining  points  they  are  almost  in- 
dispensable. 

After  the  overhanging  walls  are  cut  down,  the  auger  drills. 
Fig.  110,  ]^os.  3,  2,  6,  8,  may  be  used  to  round  and  deepen  the 
cavity,  or  they  may  be  made  to  drill  at  the  outer  end  or  point  of 


Fig.  110. 


Auger  drill. 


Round  burs. 


Odd  or  acorn. 


each  fissure  of  a  large  star-shaped  cavity,  or  to  unite  the  ra^^s  of 
a  small  one  and  make  a  plain,  round  cavity.  In  this  the  round 
burs,  Nos.  2,  3,  7,  14,  9,  12,  will  be  particularly  useful  to  assist 
the  first  named,  or  with  the  engine  they  become  the  principal 
working  tools,  enlarging,  shaping,  undercutting,  grooving  or 
guttering,  rounding  or  curving,  smoothing  and  preparing  the 
floors  and  walls;  also  in  finishing  the  concave  surfaces  of  fillings 
upon  the  masticating  surfaces  of  teeth.  The  student  may  here 
be  reminded  that  fillings  should  partake  of  the  general  shape 
externally  of  tlie  parts  of  the  teeth  in  which  they  are  placed. 
Being  designed  to  replace,  to  a  certain  extent,  the  lost  tissue 
and  protect  the  remainder  of  the  tooth-snbstance,  the  fillings 
should  rarely  project  as  full  as  the  original  material,  and  over- 
hanging edges,  except  where  the  cavities  are  countersunk  ex- 
pressly for  the  purpose,  arc  not  to  be  recommended,  as  the  thin 
edges  may  turn  uj),  break  off,  or  become  defective. 


THE    SELECTION    OF    INSTRUMENTS, 


145 


Wheel  burs,  Nos.  1,  B,  5,  7,  12, 15,  and  18,  are  auxiliary  to  the 
above,  and  are  excellent  for  flattening  floors  and  enlarging  the 
interior  of  cavities,  serving  to  make  them  slightly  larger  within 
than  at  their  openings,  giving  them  a  shallow-jar  or  pomatum- 
pot  shape.  Sometimes  they  can  be  made  of  service  in  cutting 
out  Assures,  grooving,  and  rounding,  but  they  are  invaluable  in 


Fii?.  111. 


EM 


Fisr.  113. 


Wheel  burs. 


bfi     S9    90    91    92     93 


Oval  burs. 


Fiar.  113. 


shallow  places  upon  labial  or  buccal  surfaces  to  undercut  grooves 
for  the  retaining  of  the  filling.  For  the  latter  purpose,  Xos. 
88|  to  93,  Fig.  112,  as  shown  for  the  engine  points,  are  slightly 
ovoid,  as  if  the  edges  of  the  tire 
of  the  wheel  had  been  worn  by  use. 

Palmer  s  root  or  pulp  canal  drills, 
Fig.  113,  are  of  great  value,  Nos. 
2,  3,  5,  15 ;  they  may  be  made  to 
enlarge,  straighten,  and  open  or 
ream  the  canals  to  admit  of  the 
treatment  and  filling  with  the  least 
difliculty ;  and  with  care  in  their 
use  they  will  follow  the  canal  rather 
than  cut  a  bole  through  the  side  of 
the  root — an  accident  to  be  strictly 
guarded  against. 

The  best  form  of  retaining-point 
drill  is  the  spade,  Fig.  114,  Nos.  121 
to  124,  in  the  cuts  for  the  engine- 
10 


2  3  5  15 

Palmer's  nerve,  canal  instruments. 


146         MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 
FijT.  114.  Fig.  115.  Fig.  116. 


121  to  124  161      162     163 

Retainiug-point  drills,  spade,  aud  spear-poiuts. 


r^) 


Sturap  files  and  corundum    p^        ^ 


wheels,  for  pivoting. 


points,  but  a  spear-point  drill,  Fig.  115,  may  occa- 
sionally be  used  for  this  jiurpose  where  the  corner 
of  the  spade  would  endanger  opening  into  the  pulp 
chamber.  These  are  also  useful  when  we  desire  to 
cut  to  considerable  depths,  on  entering  the  alveolus 
at  the  apex  of  the  root,  to  form  an  artificial  fistula 
for  the  relief  of  an  abscess. 

For  pivoting,  a  nearly  round  file,  as  in  Fig.  116, 
ISTos.  41,  42,  and  40,  will  be  required  for  the  old- 
fashioned  method  of  pivoting,  but  the  wn-iter  had 
the  stump  corundum  wheels  for  the  engine  made  for 
this  purpose,  and  with  these  latter  at  hand  the  use 
of  the  above  files  has  almost  been  discarded. 

The  dental  engine  is  now  so  generally  used,  that 
it  will  be  necessary  to  supplement  the  above-described 
excavators  with  a  set  of  points  that  will  be  suitahle 
for  the  many  uses  to  which  this  invaluable  addition 
to  the  dentist's  apiiliances  is  [»ut. 

Nos.  J  to  11,  Fig.  117,  represent  the  sizes  of  round 
bur  drills.  Nos.  11^  to  22,  Fig.  118,  are  wheel  burs. 
The  uses  of  the  above  points  have  already  been  described  with 
the  hand  instruments.  The  inverted  cones,  Fig.  119,  l^os.  2>^ 
to  37,  enable  tlie  operation  of  enlarging  the  fioor,or  base  of  the 
cavity,  to  be  performed  readily  and  expeditiously.  Fig.  120, 
Kos.  bb\  to  59,  is  a  set  of  fissure  drills  that  enable  the  operator 


THE    SELECTION    OF    INSTROMENTS. 


147 


to  cut  down  the  walls  and  round  out  the  points,  or  ends,  of  the 
stellate  cavities,  avoiding  the  jar  and  danger  of  slipping,  which 


Fis.  117. 


Fifr.  118. 


503  "'"'^  fFTTTTJ 


lU     12    13    14     1.5      16     17     IS      19     20      21        22 
Wheel  bur.s. 


335    34   3.)    36     37 
Invevtecl-fone  burs. 


Fiir.  121. 


5.)i   56   57    58    59 
Fissure  burs. 


66i   67  68    69     70 
Pointed  fissure  drills 


are  such  drawbacks  to  the  cutting  of  tliese  by  hand.  The  square 
ends  will  make  a  tiiiish  of  the  same  kind  on  the  floor.  Some- 
times it  is  desired  to  enter  and  enlarge  a  somewhat  smaller 
fissure,  and  after  cutting  away  the  enamel,  as  should  be  done 
with  the  chisels  and  points  already  referred  to,  p.  137,  Fig.  95, 
the  pointed  fissure  drills  ^6^  to  70,  Fig.  121,  may  be  of  service. 
The  oval  burs  Fig.  112  are  also  employed  in  the  finishing  of 
the  surfaces  of  the  fillings. 


148 


MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY, 


Fig.  122,  ISTos.  100  to  108,  shows  a  set  of  spear-point  drills 
which  enable  the  operator  to  open  into  the  pulp  cavities  of  dead 
teeth,  remove  old  fillings,  or  enlarge  or  deepen  the  cavities  to 
be  filled. 


Fig.  123. 


Fiff.  133. 


100  101  102  103  104  lOo  106 
Spear-point  drills. 


142  143  144  145  146  147  148 
Five-sided  drills. 


Fig.  114,  ISTos.  121  to  124,  are  the  spade  drills  before  mentioned 
for  cutting  retaining-pits  or  points. 

Fig.  128,  Nos.  142  to  148,  is  a  set  of  five-sided  drills  for  enlarg- 
ino;  and  makino;  true  round  holes  in  the  roots  of  teeth  designed 
to  be  pivoted. 

Fig.  124,  N^os.  200  to  204,  are  finer  cut  round  burs  for  finishing 
fillings,  or  preparing,  and  finishing  smoothly,  round  cavities. 

Fig.  125,  ISTos.  230  to  234,  are  the  useful  pear-shaped  burs  for 
the  same  purpose  as  'Nos.  200  to  204. 


Fiff.  134. 


Fi2:.  135. 


Fig.  126. 


200      202       204  230       232    234 

Fine  cut  round  liiirs.      Fine  cut  pear-sliaped  burs. 


242    243    244     245    246    247 
Sugar-loaf  drills. 


Fig.  126,  Nos.  242  to  247,  called  the  sugar-loaf  drills,  were  first 
shown  to  the  writer  by  Dr.  Louis  Jack,  whose  idea  they  embody. 
These  points  have  a  variety  of  uses  between  the  teeth  for  making 
the  now  well-known  V-shajied  o|)enings  with  curved  faces;  to 
remove  proximate  surface  8U[)erficial  decay,  and  finish  fillings 
in  the  same  situations. 


THE    SELECTION    OF    INSTRUMENTS, 


149 


Fig.  127,  Dr.  A.  W.  Holmes's  engine-bit  oiler,  is  a  neat  con- 
trivance for  keepino;  tlie  sockets  and  bits  clean  and  oiled  to  pre- 
vent rusting,  and  obviate  annoyance  in  making  the  necessary 
changes  expeditiously. 


Fiij.  127. 


FiL^  128. 


Dr.  Holmes's  engiue-bit  oiler. 


Screw-head  mandrels  with  and  without  .shoulder. 


Fig.  128  represents  the  screw-head  mandrels;  the  first  one  was 
invented  by  Dr.  Robert  Huey.  Their  use  for  carrying  disks  for 
cutting,  or  the  various  points  for  polishing,  is  so  well  suggested 
by  their  form  that  further  description  is  unnecessary. 

Fig.  l'.:9  is  a  portion  of  a  very  complete  set  of  corundum  points, 
recommended  by  Dr.  A.  L.  ISTorthrop,  of  I^ew  York.  They  may 
be  fashioned  from  broken  corundum  wheels,  or  disks,  by  warm- 
ing slightly  and  revolving  against  a  piece  of  wood. 

Fia;.  130. 


J  K 

Arkaiisas-stoue  wheels. 


Diamond-disk 
wheel. 


Fig.  130,  Hindoostan  or  Arkansas  stone  points,  for  polishing 
fillings  and  surfaces  of  teeth.  J  and  K  are  figured  as  the  most 
serviceable,  but  there  are  man}'  other  shapes  made  and  figured 
in  the  catalogrues. 


150    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

Soft  rubber  disks  (Fig.  131),  of  somewbat  similar  forms,  for 
carryiijo;  tbe  polisbing  tut  ty,  from  tljeir  pliabilit\^  may  be  brougbt 
into  contact  Avitb  many  forms  of  curved  surfaces. 

The  diamond  disk,  Fig.  132,  is  of  great  value  for  sligbtly 


Fi!?.  131. 


Fia:.  132. 


Flexible  rubber  disk  for  polishing  proximate 
surfaces  of  te'^tli  or  fillings. 


Diamond  disk  for  separating  teeth. 


separating  teetb  tbat  are  unduly  crowded  and  defective  on  tbeir 
proximate  surfaces.  Tbese  are  manufactured  of  very  thin  plates 
of  nickel  with  the  diamond  powder  imbedded  on  their  surfaces. 
Somewhat  similar  wheels  of  celluloid  and  corundum  are  like- 
wise very  useful,  and  from  their  flexibility  can  be  conformed 
somewhat  to  the  surfaces  of  the  teeth. 

JSTon-cohesive  gold  should  be  packed  as  a  lewis  is  put  into  a 
stone  for  hoisting  it,  or  much  as  damp  cigars  may  be  packed 
into  a  tumbler,  pressing  a  wedge  into  the  middle,  and  forcing 
the  cigars  against  the  sides  and  putting  fresh  ones  in  the  centre 
until  full.  For  fillings  of  this  description  the  gold  may  be  pre- 
pared in  cylinders  by  rolling  upon  a  watchmaker's  fine  broach. 
The  three-sided  are  preferred.  To  accomplish  this  Abbey's  jSTo. 
6  non-cohesive  gold  foil  ma^'  be  twice  folded  in  the  book  by 
turnincr  the  outside  edge  of  the  leaf  to  the  centre  and  then 
making  this,  by  a  second  folding  in  the  same  manner,  one-quarter 
of  the  original  size,  and  of  four  thicknesses,  like  a  miniature 
folded  newspaper  or  quarto.  This  folded  sheet  is  then  cut  into 
strips  or  ribbons  or  tapes,  in  width  equal  to  about  one-third 
more  than  the  depth  of  the  cavity.  The  end  of  the  tape  is 
laid  upon  the  index  finger  of  the  left  hand,  the  broach  put 
across  the  extreme  end,  and  the  thumb  of  the  same  hand  then 
laid  on  this.  By  drawing  the  thumb  over  the  broach  and  rib- 
bon toward  the  free  end  of  the  latter,  the  gold  is  wound  tightly 
on  the  steel  broach,  and  then,  by  guiding  the  ribbon  straight 


THE    SELECTION    OF    INSTRUMENTS.  151 

with  these  fingers,  the  handle  of  the  broach  may  be  twirled 
between  the  thumb  and  index  tinger  of  the  right  hand,  making 
tlie  gold  into  a  tightly  rolled  (-3  linder,  the  ends  of  which  are 
formed  by  the  edges  of  the  ribbon,  and  appearing  something  like 
a  diminutive  block  of  the  kind  used  by  milliners,  a  true  cylin- 
der, not  bulging  like  a  barrel  in  the  centre.  The  back  of  the 
thumb-nail  of  the  left  hand  may  be  pressed  against  the  end  of 
the  cylinder  as  it  is  finished,  and  the  edge  of  the  nail  held  upon 
the  broach  while  the  latter  and  the  cylinder  are  revolved.  After 
this  the  cylinder  may  be  carefully  pushed  ofi' the  broach  by  the 
thumb-nail  f)f  the  right  hand  or  a  pair  of  [>liers,  taking  care  not 
to  unwind  the  gold. 

Ropes  are  made  by  folding  the  same  foil  into  strips  or  ribbons 
one-fourth  or  one-sixth  the  width  of  the  sheet,  taking  care 
that  the  edges  are  inwards,  and  then  twisting  the  ribbon  tightly 
between  the  forefingers  and  thumbs,  making  it  unitbrm  in  den- 
sity. To  finish  a  rope  neatly  it  may  be  rolled  between  two 
pieces  of  plate  glass  until  a  degree  of  density  is  obtained  that 
is  uniform  and  the  rope  smooth  surfaced.  The  rope,  as  first 
recommended,  may  be  made  of  half  or  quarter  sheets  for  very 
small  cavities,  and  it  is  generaly  best  cut  into  short  pieces  from 
one-sixteenth  to  one-fourth  of  an  inch  in  length.  These  may 
be  used  much  like  the  cigars  above  mentioned,  or  as  cylinders, 
being  stood  upon  their  ends  upon  the  fioor  of  the  cavity  and 
allowed  to  project  in  tight  cylinders  equal  to  one  third  of  the 
depth,  or  in  loose  ropes  rather  more  than  the  depth  of  the  hole. 
They  should  be  shajied  to  the  w^alls  by  pressure  at  a  right  angle 
to  the  latter,  or  in  the  direction  of  the  spokes  of  a  wheel  toward 
the  rim.  The  last  cylinder  or  piece  of  rope,  will  be  the  key 
piece  to  the  whole,  acting  like  the  hub  of  a  wheel  to  press  out- 
wards toward  the  walls.  The  softest  cylinders  are  used  against 
the  walls,  and  the  hardest  for  the  centre  or  key  pieces. 

In  such  operations,  the  last  stage  of  filling  consists  of  con- 
densing upon  the  ends  of  the  cylinders  or  ropes,  pressing  the 
projecting  gold  into  the  cavit}-,  and  finishing  up  by  filing  or 
burring  and  burnishing  alternately,  until  the  whole  surface  is 
flush  with  that  of  the  tooth,  and  uniforndy  hard,  and  capable 
of  a  high  polish,  which  latter  is  desirable  as  preventing  the 
lodgment  of  food  or  any  deleterious  matter  about  the  edges  or 
surface. 


152    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

Tapes  may  be  made  of  tlie  same  gold  by  folding  or  cutting 
into  strips  as  before  described,  and  these  may  be  packed  in 
alternate  foldings  and  refoldings,  so  that  the  layers  when 
finished  will  run  perpendicularly  to  the  floor  of  the  cavity. 
Long  tapes  and  ropes  are  in  danger  of  being  moistened  and 
ruined  by  the  saliva  of  the  mouth.  They  are  best  cut  into 
pieces  as  described,  one-sixteenth  to  one-fourth  of  an  inch  long. 

The  condensation  of  the  filling  should  be  commenced  with 
coarse  and  heavy  points  and  finished  with  smaller  ones,  testing 
the  density  by  boring  with  a  slight  brad-awl-like  movement  of 
the  instrument's  point,  and  if  found  to  penetrate,  enlarging  the 
opening  to  its  utmost  and  filling  the  hole  made  by  another 
pellet  or  cylinder. 

Cohesive  gold  should  be  prepared  by  folding  as  above,  using 
Abbey's  'No.  4  foil,  and  cutting  or  tearing  with  instrument 
points  into  pieces  havingfrom  four  to  eight  thicknesses,  and  about 
one-thirty-second  to  one-fourth  of  an  inch  square.  The  greatest 
pains  must  be  taken  to  preserve  it  free  from  moisture,  from 
breath  condensation,  or  any  cause ;  also  from  all  other  foreign 
substances,  as  grease,  saliva,  dust,  etc.,  as  they  will  impair  its 
working  property,  which  depends  upon  the  cohesion.  Unlike 
the  former  gold,  which  was  recommended  to  be  worked  like 
piling  to  fill  a  cavity,  this  operation  should  be  commenced  by 
anchoring  the  gold  in  retaining  points,  except  in  very  small 
cavities,  on  the  floor,  and  building  up  like  masonry,  laying  the 
pieces  so  as  to  break  joints  with  each  other,  carrying  each  layer 
parallel  to  the  floor,  or  horizontally  with  the  general  direction 
of  the  floor,  or  at  right  angles  to  the  axis  of  the  cavity.  The 
general  princii>les  of  architecture  and  engineering,  the  arch  and 
buttresses,  trussing,  bolting,  screw  piles,  etc.,  must  be  followed 
upon  a  very  minute  scale.  Sometimes,  in  moderately  small 
cavities,  say  one-eighth  to  one-fourth  of  an  inch  in  diameter,  with 
smooth  rounded  walls,  cohesive  gold  may  be  [)acked  against  them, 
a  little  higher  than  in  the  centre,  by  using  Dr.  Benj.  Lord's  plug- 
gers  presently  to  be  described.  But  in  larger  cavities  there  is 
always  danger  of  the  gold  bridging  over,  causing  defects  and 
hollow  spaces,  which  impair  the  value  of  the  filling. 

From  the  difierence  in  the  manner  of  using  non-cohesive 
and  cohesive  gold,  it  may  be  inferred  that  a  set  of  instruments 
specially  designed  for  each  will  be  required.     The  first  being 


THE    SELECTION    OF    INSTRUMENTS, 


153 


wedged  into  the  cavity,  will  require  slightly  tapering  points, 
and  often  deep  serrations,  to  prick  the  gold  pellets  one  into  the 
other.  (See  Fig.  133.)    Nos.  9,  99,  101,  1,  4,  127,  and  128  of  the 


Fiff.  133. 


10  n         12       127 

Ellis's  pluggei's. 


9         99  101        4  3 

New  York  set  of  pluggers. 


Dr.  Lord's  pluggers  and  burnishers. 


ISTew  York  set  are  selected,  together  with  (Fig.  138)  JSTo.  3  of 
Prof.  E.  T.  Darby's  set ;  also  a  bayonet  packer  and  condenser. 
Dr.  a.  W.  Ellis's,  JS'os.  11, 1 2,  and  10,  Fig.  133,  may  be  used 
foreither  kind  ofgold,asalso  may  Dr.  Benj.  Lord's  (Fig.  133.) 


154        MANUAL    OF    DE^;TAL    SURGERY    AND    PATHOLOGY. 

The  latter  are  remarkable  from  their  general  resemblance  to  the 
linger  or  hand  of  man,  and  render  packins^  almost  so  easy  of 
accomplishment  with  them  as  to  need  no  further  description. 
The  two  on  the  right  of  the  cut  are  for  burnishing.  These 
j>oints  are  on  unpolished  handles  and  shafts,  which  afford  a 
better  grasp,  without  being  so  roughened  bj'  file  cutting  as  to 
make  the  corn-like  callous  spots  upon  the  hand  and  fingers  of 
the  operator. 

Dr.  Louis  Jack's  matrix  pluggers  (Fig.  134)  are  designed  by 
him  for  use  with  his  matrices,  as  shown  hy  the  Fig.  134.  They 
are  principally  useful  on  proximate  surfaces,  the  matrices  being 
wedged  into  position  by  pressing  between  the  teeth,  using 
wooden  wedges  if  necessary.  The  latter  are  recommended  to 
be  made  of  boxwood,  which  is  now  obtainable  at  the  dental 
depots,  cut  into  thin  strips  of  different  sizes  appropriate  for  the 
purpose.  The  cavities  are  prepared  by  cutting  away  the  over- 
haugins;  crown-surfaces  so  as  to  obtain  a  full  view  of  their  inte- 
rior. After  the  removal  of  the  decay,  the  floors  are  flattened 
or  rounded,  aud  a  retaining  point  cut  on  either  side,  clear  of 
the  pulfHchamber.  These  may  be  united  by  a  shallow  groove 
if  desired,  aud  grooves  running  from  them  to  the  cutting  or 
masticating  face  will  hold  the  filling  material  in  position.  The 
filling  is  accomplished  by  wedging  a  cj^linder  or  pellet  of  non- 
cohesive  gold  into  either  retaining  point,  with  its  side  against 
the  floor,  and  one  end  abutting  againt  the  tooth  and  the  other 
against  the  matrix,  which  is  [)laced  in  position  after  the  cavity 
has  been  prepared.  A  third  piece  of  gold  is  driven  between 
these  two,  as  in  the  lewis,  to  wedge  and  hold  them  in  position, 
and  the  whole  layer  is  now  thoroughly  condensed  against  the 
walls.  The  filling  is  to  bo  finished  up  to  near  the  masticating 
face  b\'  successive  la^'ers,  as  just  described,  taking  care  to  drive 
the  gold  with  the  long  serrations  of  the  pluggers  tightly  against 
the  walls  and  the  polished  surfaces  of  the  steel  matrices,  and 
over  each  retaining-point  making  a  \nt  in  the  gold  b}'^  driving 
a  plugger  in  each  layer  to  leave  a  corresponding  pit  for  anchor- 
age of  the  next.  The  filling  may  be  finished  with  cohesive  foil 
at  the  top,  where  the  wear  of  mastication  is  greatest. 

If  properly  made,  when  the  matrix  is  removed,  but  little 
work  will  be  required  to  finish  the  filling,  as  the  smooth  steel 


THE    SELECTION    OF    INSTRUMENTS, 
Fig.  134. 

I C ^---J  ^ 

l)r.  Jack's  matrix. 


loo 


Dr.  Jack's  matrices. 


Dr.  L.  Jack's  matrix  plagger,  maenified. 


5  liiacnces. 


156 


MANUAL    OF    DENTAL    SURfiERY    AND    PATHOLOGY 


I  surface  of  the  matrix  leaves  the  gold  almost  ready  for  the 

^   burnisher. 

A  set  (Fig.  135),  called  in  the  catalogues  after  the 
writer,  but  really  only  selected  and  arranged  by  him, 'has 
been  designed  for  hand  or  mallet  pressure,  and  may  be 
used  for  cohesive  gold  when  the  serrations  are  new  and 
sharp,  they  being  shallow  and  of  the  patterns  most  gene- 


5  6  7  S 

Hand  or  mallet  pluggers. 


1  S  2 

S.  S.  W.  burnibliers. 


9  10 

Prof.  E.  T.  Darby's  burnishers. 


E  H  J 

Engine  biirnishors. 


THE    SELECTION    OF    INSTRUMENTS, 


157 


rally  used.  As  the  instrnmeiits  become  worn  by  use,  they  will 
serve  nicely  to  condense  the  surfaces  of  fillings. 

Fig.  135  gives  patterns  of  the  most  useful  shapes  of  burnishers 
— Nos.  1,  8,  and  2,  of  the  S.  S.  W.  set,  for  general  use,  and  Prof. 
Darby's,  ISTos.  31  and  32,  for  proximate  surfaces  and  fissures. 

Fig.  135,  l^os.  E,  H,  J,  give  the  smooth-pointed  burnishers 
for  the  dental  engine. 

Fig.  136  represents  Prof.  J.  Foster  Flagg's  patterns  of  1)1  ug- 
ging  forceps,  which,  for  non-cohesive  gold,  afford  a  very  easy 


Fig.  136. 


Prof.  J.  F.  Flagg's  condensing  forceps. 


Weston's  amalgam  pluggers. 


but  powerful  means  of  getting  desirable  density  and  finish. 
The  plain  beak  is  put  upon  the  side  of  the  tooth,  which  may  be 
protected  by  some  intervening  substance  if  desired,  and,  using 
this  as  a  fulcrum,  the  other  beak  is  pressed  upon  the  gold. 

Fig.  136,  Nos.  6  and  8,  Dr.  Weston's  patterns  of  amalgam 
pluggers,  may  be  added. 

The  bottom  of  the  case  will  serve  as  a  general  receptacle  for 
gold,  polishing  powders,  napkins,  four  and  six  inches  square,  for 
keeping  the  cavities  dry,  amadou,  bibulous,  blotting,  and  test 


158    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

papers.     Rubber  dam  and  punches,  clamps,  holders,  and  wedge- 
cutters  for  use  with  the  same,  may  here  be  kejtt. 

A  hand  magnifying-glass  is  useful  to  examine  debris  in  exca- 
vating, surfaces  of  fillings,  etc. 

An  ivory  paper-folder  will  be  of  service  for  folding  the  gold, 
and  may  be  kept  here. 

Fig.  187. 


Dr.  Corydon  Palmer's  metal  tube  with  lead  fllllug  fur  iiiallet-head. 


THE    SELECTION    OF    INSTRUMENTS. 


159 


The  mallet  (Fig.  137),  as  designed  by  Dr.  Corydon  Palmer,  is 
best  kept  in  the  tray  with  the  plugging  instruments.  This 
pattern  of  mallet  has  the  lead  run  into  a  i)iece  of  metal  piiie  to 


Fii?.  138. 


Fi?.  139. 


Cutting  pliers. 


Wedge  pliers.     Dr.  Corydou 
Palmer's  i)atterii. 


160    MANUAL  OF  DEXTAL  SURGERY  AND  PATHOLOGY. 

prevent  its  spreading  at  the  ends  or  faces  by  use.  This  mallet 
may  weigh  half  a  pound,  and  is  best  used  with  a  dead  or  push- 
ing blow. 

A  cutting  plier,  Fig.  138,  will  also  be  of  service  for  cutting  off 
woodeu  wedges  in  separating  teeth,  or  projecting  spiculas  of  the 
septum  of  bone  between  the  alveoli  after  extraction  of  the  teeth  ; 
also  a  pair  of  pliers.  Fig.  139,  for  removing  the  wooden  wedge 
after  finishing  the  operation.] 


TREATMENT  OP  DENTAL  CARIES.  161 


CHAPTER    VIII. 

treatmi:nt  of  dentai.  caries. 

The  first  consideration  with  regard  to  any  disease  should 
certainly  be,  if  possible,  its  anticipation  and  prevention  ;  and 
it',  in  Chapter  VI.,  we  have  at  all  rightly  comprehended  the 
nature  of  dental  caries,  or  the  conditions  which  favor  its  exist- 
ence, we  may  approach  the  subject  with  some  confidence  of 
success. 

[Exercise,  of  an  earnest  and  even  laborious  character,  has  long 
been  looked  upon  as  a  safe,  sure,  and  sensible  tonic  treatment 
to  bring  about  a  normal  appetite  for  normal  food.  The  Greeks 
liad  their  palfestra  and  gymnasia,  in  the  open  air,  or  for  bad 
weather  under  colonnades  ;  the  moderns  have  substituted  the  ill- 
ventilated  gymnasium.  But  a  ride  on  horseback,  or  a  game  of 
ball,  or  any  exercise  with  the  stimulus  of  an  object  to  be  attained, 
far  outweighs  in  benetit  derived  the  mere  labor  for  labor's  sake.] 

First,  with  regard  to  food,  we  can  now  generally  obtain  bread 
made  from  the  whole-meal  flour,  which,  if  not  quite  so  palatable 
at  first,  becomes  to  children  brought  up  on  it  preferable  to  any 
other.  With  regard  to  meat  we  can  say  little.  Some  attribute 
the  early  loss  of  the  teeth  to  eating  too  large  a  proportion  of  it; 
but,  if  so,  surely  the  Esquimaux  ought  to  suffer  considerably, 
whereas  they  have  probably  the  finest  teeth  of  any  nation  under 
the  skies;  on  the  other  hand  are  tribes  having  excellent  teeth 
who  are  almost  entirely  vegetable  feeders.  For  children  we 
would  request  the  indulgence,  viz.,  that  during  the  period  of 
their  nurseryhood  they  bo  freely  supplied  with  bones  on  which 
to  exercise  their  teetli  and  gums.  A  child's  invariable  predilec- 
tion for  a  bone  to  suck  and  gnaw  must  be  some  strong  dictate 
of  nature,  and  the  freedom  of  a  bone  from  all  else  than  bone, 
after  it  has  been  in  a  child's  possession,  proves  that  nature  most 
successfully  fulfils  her  own  demands. 

We  have  spoken  of  the  knife  and  fork,  which  we  believe 
11 


162    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

have  nineh  to  answer  for;  or,  perliaps,  rather  the  civilization 
wliieh  has  introduced  them,  and  holds  them  too  dear  to  think 
of  ever  giving  them  up.  But  the  same  civilization  has  to  some 
extent  atoned  by  the  introduction  of  the  tooth-brush,  a  thorough 
employment  of  which  latter  -will  to  a  great  extent  counteract 
the  evils  of  the  former,  as  well  as  those  arising  from  many  other 
causes.  The  Chinese  are  and  have  long  been  a  civilized  nation, 
and  as  a  rule  have  excellent  teeth  ;  but  every  house  has  its 
family  tooth-brush,  as  well  as  its  comb  and  its  tongue-scraper, 
and  the  teeth  are  scrupulously  cleansed  after  every  meal.  At 
the  head  of  his  boat,  where  would  in  England  be  seen  a  short 
jjipe,  the  Canton  boatman  fixes  his  tooth-brush,  read}'  for  use 
after  every  meal;  and  in  like  manner  do  most  Indian  tribes  of 
both  the  new  and  old  worlds  who  live  on  soft  food  carefully 
cleanse  their  teeth  after  eating,  with  a  species  of  cane  root  or 
even  hard  wood.  Thorough  brushing  after  every  meal  is 
strongly  to  be  recommended,  and,  if  this  were  practised,  water 
alone  would  suffice ;  still  there  can  be  no  objection  to  the  occa- 
sional emplo^'ment  of  a  dentifrice,  of  which  none  can  be  better 
than  a  mixture  of  pure  soap  and  precipitated  chalk;  in  some 
cases  an  antiseptic  may  be  added,  such  as  tinely  powdered  puri- 
fied charcoal,  but  these  are  generally  best  used  separately,  and 
a  pleasant  and  effective  one  is  Eau  de  Cologne  diluted  with 
water,  to  which,  when  the  secretions  of  the  mouth  appear  acid, 
a  little  salvolatile  ma}'-  advantageously  be  added.  [Charcoal, 
while  unsurpassed  as  a  purifier  in  the  form  of  a  dentifrice,  has, 
like  all  insoluble  materials,  the  insuperable  objection  of  being 
liable  to  work  up  between  the  teeth  and  the  free  margins  of 
the  gums,  w^here  the  spiculfe  initiate  a  disease,  the  absorption  of 
tiie  alveolar  processes,  which  may  continue  throughout  life  and 
eventually  eflect  the  loss  of  the  teeth  by  loosening  their  attach- 
ments.] Cases  in  which  the  foregoing  reconmiendations  have 
been  scrupulously  followed  sjieak  for  themselves  when  com- 
pared with  those  where  no  such  care  has  been  exercised,  and 
this  especially  is  the  case  with  children.  It  is  a  very  common 
error  to  argue,  that,  because  animals  employ  no  tooth-brush  and 
yet  have  excellent  teeth,  that  appliance  cannot  be  necessary. 
An  animal's  tooth-brush  is  its  proper  food,  which,  if  changed 
for  an  improper  one,  will  often  result  in  injury  to  the  teetb. 
But  we  must  now  direct  our  attention  to  cases  in  which  the 


TREATMENT    OF    DENTAL    CAKIES.  163 

disease  has  actually  made  its  appearance,  and  first  we  take  those 
cases  in  which  it  has  either  very  recently  commenced  or  advanced 
very  slowly  and  superficially,  and  for  such  cases  the  operation  of 
excision  is  often  the  most  suitahle.  In  performing  this  opera- 
tion it  is  essential  that  the  surface  or  part  excised  shall  become 
free  and  exposed  to  the  action  of  the  tongue  or  lips,  or,  in  other 
words,  so  left  that  food  shall  no  longer  be  able  to  lodge  or  re- 
main in  contact  with  it.  The  cases  the  most  suitable  for  excis- 
ion then  are  those  in  which  the  disease  has  made  its  appearance 
on  the  ajiiiroxiraal  surfaces  of  the  upper  front  teeth,  and  more 
towards  their  posterior  than  their  anterior  ones,  for  there  it  can 
be  cut  away  without  any  observable  disfigurement  and  shelved 
oft"  into  the  posterior  surface  of  the  tooth,  where  the  movements 
of  the  tongue  will  prevent  the  lodgment  of  food.  When  the 
disease  is  quite  superficial,  and  situated  on  the  crown  of  molars, 
bicuspids,  or  cuspidati,or  on  the  approximal  surfaces  of  the  two 
former  at  or  near  to  their  masticating  surfaces,  which  when  cut 
out,  will  leave  a  V-shaped  space  between  those  teeth,  excision 
may  also  be  well  employed.  The  operation  will  be  best  per- 
formed by  first  cutting  away  all  overhanging  enamel  with  small 
highly-tempered  chisels,  termed  enamel-cutters,  the  force  being 
employed  as  far  as  possible  in  the  line  of  the  enamel-fibres,  as 
the  structure  yields  most  readily  in  that  direction.  To  prevent 
the  instrument  from  slipping  and  iiijuring  adjacent  parts,  it 
should  be  held  near"  to  the  cutting  edge  and  governed  by  the 
thumb  f)f  the  hand  grasping  it,  the  thumb  resting  upon  that 
operated  on,  or  an  a(ljf)ining  tooth.  Having  removed  most  of 
the  overhanging  enamel,  the  ojierator  will  next  do  well  to  scrape 
away  with  an  excavator, — a  smaller  description  ot"  cliisel  to  be 
firesently  described, — all  softened  dentine,  as  tliis  will  aftbrd 
him  a  certain  knowledge  of  the  dei)th  of  the  diseased  structures, 
and  perhaps  lead  him  to  discover  that  the  operation  of  excision 
is  not  suitable  for  the  case  before  he  has  advanced  too  far  in  it. 
The  softened  dentine  being  removed,  the  enamel-cutter  is  again 
employed  until  the  surface  is  rendered  level,  or  nearly  so,  when, 
Avith  tiles  curved  and  bent  so  as  to  reach  otherwise  inaccessible 
places,  a  perfectly  smooth  surface  is  obtained,  and  may  be  finally 
polished  by  rubbing  it  with  finely  pcnvdered  pumice  and  water 
applied  on  a  pointed  piece  of  wood.  [To  obtain  a  more  highly 
]iolished  surface,  many  operators  then   use  polishingputty  or 


164   MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY, 


Fig.  140 

f 


<^ 


I    n 


A  variety  of  forms  of  enamel  chisels  or  cutters.     The  forms  given  will,  we  believe,  be  found  the 

most  useful  in  practice. 

tuttj  (the  peroxide  of  tin),  which  is  applied  in  a  similar  man- 
ner. For  approximal  surfaces  it  may  be  placed  upon  tape,  or 
probably  better,  the  old-fashioned  oil  lamp-wick,  that  has  been 


TREATMENT    OF    DENTAL    CARIES, 
Fisr.  141.  Fiff.  142. 


165 


I 

I 
I 


I 


Fig  141.  Very  serviceable  paraboloid  and  gunge  oliisels  of  Dis.  J;ick  <iud  I'orbes.  Fig.  142 
shows  the  S.  S.  White  dental  engine.  The  fly-wheel  rotated  by  a  treadle,  gives  movement  to 
the  hand  which  turns  the  small  wheel  at  the  top  of  the  instrument  with  multiplied  velocity. 
The  small  wheel  is  attached  to  a  wire  cord  which  passes  in  the  centre  of  the  flexible  stem  con- 
nected with  the  mandrel,  and  terminates  in  an  arrangement  in  the  latter  which  securely  holds 
a  burr  or  other  instrument.  To  the  instrument  a  very  rapid  rotatory  motion  is  given,  whilst  the 
flexibility  of  the  stem  and  wire  cord  permit  at  the  same  time  its  movement  in  almost  any  direc- 
tion. 


166    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

moistened.  With  the  engine  a  piece  of  cotton-wool  rolled 
upon  a  broken  point  will  make  a  useful  carrier,  or  for  approxi- 
mal  surfaces,  elastic  vulcanized  rubber  or  vulcanized  fibre  or 
felt,  especially  prepared  by  pressure  and  made  into  tbin,  stiff 
disks,  greatly  facilitates  the  operation.] 

Tlie  process  of  filing  and  polisbing  can  be  much  more  readily 
and  efi:ectually  conducted  by  what  is  termed  the  "  dental  or 
burr  engine,"  a  very  clever  machine,  which,  worked  by  the  foot 
like  a  lathe  or  sewing-machine,  gives  to  a  small  file  or  other 
instrument, — in  this  case  more  particularly  a  small  corundum 
wheel  or  point,  —  a  rotary  movement  continuous  with  other 
movements,  which  allow  of  application  and  removal  within 
considerable  limits,  for  which  valuable  invention  we  were  first 
indebted  to  our  American  confrere  Morrison.  If  the  conditions 
be  suitable  and  the  operation  boldly  performed,  it  will  generally 
prove  very  successful,  especially  if  the  patient  be  careful  to 
brush  or  rub  such  surface  frequently.  We  have  seen  cases 
standing  well  where  it  had  been  performed  thirty  or  even  forty 
3"ear8  previously.  We  sometimes  see  the  same  result  naturally 
accomplished,  viz.,  where  much  enamel  has  broken  away  from 
a  superficial  carious  surface,  or  where  a  tootii  removed  allows 
the  opportunity  for  the  tongue  to  keep  such  surface  clean  and 
polished.  It  frequently  occurs  that  the  surface  treated  as  above 
is  left  very  sensitive  to  hot  and  cold  ai)plications :  this  will  after 
a  time  subside  of  itself,  but  may  be  speedily  lessened  by  a  frequent 
application  of  salvolatile,  which,  indeed,  appears  also  to  harden 
such  surface. 

Where,  and  as  more  frequently  is  the  case,  the  disease  has 
made  greater  progress,  or  is  situated  so  that,  after  excision,  the 
tongue  cannot  get  access  to  the  spot,  the  process  of  filling, 
stopping,  or  plugging,  as  it  has  been  variously  called,  must  be 
employed.  This  consists  in  removing  all  the  diseased  or  soft- 
ened portion  of  the  tooth,  and  substituting  for  it  some  other 
substance  capable  of  fulfilling  to  the  greatest  extent  the  condi- 
tions and  qualities  of  the  structure  lost.  Such  substance  should 
combine,  if  possible,  the  following  conditions,  viz.:  1.  Freedom 
from  liability  to  cause  irritation  ;  2.  Capability  of  being  intro- 
duced in  a  soft  state,  and  then,  without  change  of  bulk,  becom- 
ing hard  enough  to  resist  the  friction  and  wear  of  mastication; 
3.  Power  of  resisting  to  a  considerable  degree  the  action  of 
chemical  reagents,  or  the   eftects  of  any  such  temperature  as 


TREATMENT  OF  DENTAL  CARIES. 


167 


[Fig.  143. 


Fis:.  144. 


<30 

Corundum   points    used 
with  the  dental  engine. 


The  S.  S.  White  water  motor,  dental  engine.] 


168    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

could  he  tolerated  in  the  month;  4.  The  qualities  of  possessing 
an  unehangeahle  color,  and  of  resemhling  the  enamel  of  teeth. 
Substances  possessing  several  of  the  above-mentioned  qualities 
are  in  use  for  the  purpose  of  filling  teeth,  but  unhappily  at  present 
there  is  not  one  known  which  combines  them  all.  Every  one  of 
these  substances  fails  in  one  or  more  of  such  qualities,  and  there- 
fore the  operation  of  filling  teeth,  probably  the  most  successful 
of  any  in  surgery  when  properly  performed,  must  3'et  be  regarded 
as  imperfect.  We  shall  lirst  describe  the  mode  of  removing  the 
softened  disorganized  dentine,  and  preparing  the  cavity  thus 
made  for  receiving  one  of  the  above-mentioned  substances,  and 
then  ])oint  out  their  mode  of  application,  with  the  various 
qualifications  and  disqualifications  of  each.  As  previousl}'- 
noticed,  we  shall  generally  find  that  the  dentine  has  suffered  to 
a  greater  extent  than  the  superimposed  enamel,  and  therefore, 
to  insure  the  thorough  removal  of  the  softer  portions  of  the 
former,  we  must  sacrifice  some  of  the  latter,  and  this  maj^  be 
most  easily  and  eftectually  done  by  a  cautious  use  of  the  enamel- 
cutters. 

At  the  first  aspect  it  would  no  doubt  generally  appear. that 
the  form  of  cavity  most  suitable  for  retaining  a  foreign  substance 
would  be  cavernous,  i.  e.,  having  an  orifice  smaller  than  the 

Fiflr.  145. 


The  typical  form  of  a  cavity  when  prepared  for  receiving  a  filling:  in  the  dentine  it  represents 
a  truncated  cone,  the  base  of  which  is  the  bottom  of  the  cavity,  whilst  in  the  enamel  it  is  bevelled 
off  in  the  opposite  direction. 

cavity  itself  [The  object  of  the  dentist  in  preparing  a  cavity 
for  tilling,  should  be  to  avoid  making  sharp  corners  or  angles, 
as  they  are  n)ore  difticult  to  adapt  the  gold  or  other  filling  ma- 
terial to.  Indeed  with  amalgam,  owing  to  its  tendency  to  ball, 
or  form  splierf)ids,  our  latest  authorities  recommend  that  the 
cavities  should  be  shaped  to  correspond  with  the  forms  most  likely 
to  be  assumed.]'     In  })ra<ttice  it  is,  however,  found  that  a  cylin- 

['  "Plastics  and  Plastic  Filling,"  by  Prof.  J.  Foster  Flagg,  D.D.S.,  p.  81. 
Presley  Blakiston,  Phila.,  1881.] 


TREATMENT    OF    DENTAL    CARIES.  160 

<lrio{il,  or  tiearly  cylindrical,  form  will  be  the  hest ;  the  most 
perfect  being  slightly  conical  in  the  dentine,  the  base  being  the 
bottom  of  the  cavity,  and  the  same  in  the  enamel,  but  reversed; 
in  fact,  two  cones  meeting  towards  their  truncated  apices.  It 
will,  of  course,  be  impossible  in  many  cases  to  obtain  a  cavity 
of  such  form,  but  taking  it  for  a  type  we  may  always  endeavor 
to  obtain  some  approximation  to  it.  Where  the  orifice  to  the 
softened  dentine  is  small  or  narrow,  we  shall  best  enlarge  it  by 
the  broach  or  burr  drill,  the  former  a  kind  of  five-cornered  drill, 
the  latter  a  file  to  be  rotated.  Sufficient  enamel  having  been 
removed  to  allow  the  use  of  excavators,  if  necessary — for  small 
cavities  may  be  entirely  cleared  out  by  the  broach  or  burr  drill 
— the  softened  dentine  is  scooped  out  until  a  clear  and  ringing 
sound,  and  sensation  of  density  to  the  fingers,  announce  that  this 
portion  of  the  process  is  com.pleted.  The  excavators  before  men- 
tioned are  small  chisels,  or  scoops,  and  may  be  obtained  of  suit- 
able sizes,  and  almost  ^very  form  conceivable,  to  reach  cavities 
in  obscure  places.  They  should  be  made  of  the  best  steel,  tem- 
pered high  at  their  points,  but  low  just  beyond  where  the  instru- 
ment becomes  thin,  and  frequently  bent  at  an  angle.  Great 
difference  of  opinion  in  regard  to  their  form  may  be  exercised 
without  prejudice;  but  in  our  experience  those  having  the  cut- 
ting extremity  resembling  a  spoon  do  the  work  most  rapidly 
and  thoroughly,  and  with  less  risk  of  penetrating  to  dangerous 
places  than  those  having  the  ordinary  chisel  points.  It  is  well 
for  the  beginner  to  endeavor  to  ascertain  at  the  outset  the  most 
useful  forms,  and  those  especially  adapted  for  the  greatest  variety 
of  cases,  there  being  much  loss  of  time  and  fatigue  in  having 
continually  to  change  the  instruments.  The  defective  dentine 
will  be  soft  in  proportion  to  the  rajiidity  of  the  disease,  and 
generally  sensitive  in  the  same  ratio.  Whilst  it  is  most  desirable 
that  all  the  softened  and  diseased  dentine  should  be  removed,  it 
is  yet  all-important  that  the  vascular  and  nervous  portions  which 
occujiy  the  central  cavity  in  the  tooth  should  not  be  injured  or 
exposed  ;  and  the  student  will  do  well  to  avail  himself  of  oppor- 
tunities of  splitting  into  sections  extracted  teeth,  in  order  to  gain 
a  lively  recollection  of  the  relative  positions  of  the  so-called  pulp. 
After  removal  of  the  softened  dentine  it  will  often  be  found  that 
the  resulting  cavity  is  too  shallow  and  too  saucer-shaped  to  re- 
tain a  tilling;  under  these  circumstances  some  of  the  healthy 


170 


MANUAL    OP    DENTAL    SURGERY    AND    PATHOLOGY. 


structure  must  be  sacrificed.  Here  excavators  of  the  chisel  form 
will  be  most  effective:  they  should  be  made  very  sliarp  and  ap- 
plied with  a  firm  and  unvibrating  stroke  to  a  dried  surface, 
which  reduces  the  amount  of  pain  experienced. 


Fin-.  146. 


Fi^.  147. 


|l!i!i^^^=s=9 


Fig.  148. 


Fisr.  149. 


Figs.  146,  147,  14S,  and  149,  various  fovnis  of  niauiliel  or  handpiece  for 
the  dental  engine,  146  straight,  147  right  angle,  148  acute  angle,  140  obtuse 
angle.    In  Fig.  146  is  shown  the  method  for  securing  the  instrument  or  hit. 

.[Recent!}^  the  writer  has  been  using  a  univer- 
sal handpiece,  of  pattern  devised  by  Dr.  II.  C.  Re- 
gister, having  a  device  for  griisping  and  centering 
anv  ordinary  drill.     The  construction  seems  to  be 
very  simple  and  effective,  resembling  the  universal 
lathe-cliuck.     In  addition  to  the  ease  with  which 
points  may  be   changed  in   it,  the  grip   of  the  tool  is  equally 
firm  whether  revolved  to  the  right  or  left.     The  latter  is  of 
great  advantage  when  running  the  disk  between  teeth,  as  the 
cutting  is  less  unpleasant,  and  the  wheel    less   likely  to  jam 
when  it  cuts  in  the  direction  from  the  necks  towards  the  edges 
or  masticatino;  faces  of  the  teeth. 


TREATMENT  OF  DENTAL  CARIES.  171 

For  painless  excavation,  the  scoops  fire  rapidly  chaining 
friends,  because  tliey  etiable  tlie  operator,  by  passing  down  to 
the  floor  of  tlie  cavity,  with  a  few  swee[.ing  rotary  cuts,  to 
sever  the  connection  with  the  pulp  of  the  dentine  to  be  re- 
moved ;  then,  by  drawing  the  instrument  outwards  toward  the 
enamel,  the  debris  is  drawn  out  almost  without  sensation.  In 
this  way,  with  a  little  care  and  skill  from  practice,  it  frequently 
happens  that  the  pulp  of  the  tooth  may  be  uncovered  of  its 
overlying  softened  carious  dentine  without  a  single  complaint 
from  the  patient. 

It  may  also  be  added  that  the  scoop  is  of  almost  universal  use. 
Upon  turning  the  edge  downward,  the  overhanging  enamel  and 
perpendicular  walls  may  be  cut.  Fissures  may  be  followed  up 
by  the  same  movement,  which  can  be  assisted  by  a  slight  or 
partial  rotation  of  the  instrument  upon  its  axis.  For  many 
cases  one  or  two  sizes  of  scoops,  say  ISTos.  68  and  67,  will  be  all 
that  are  required  to  prepare  a  tooth  for  filling.] 

When  it  can  be  tolerated,  the  healthy  dentine  is  most  readily 
removed  with  burrs  rotated  by  the  engine,  and  which  can  be 
applied  at  almost  any  angle.  It  is  desirable,  after  removal  of 
the  dentine,  to  render  smooth  the  enamel  where  cut  by  enamel- 
cutters,  either  by  the  file  or  by  the  corundum  point  with  the 
engine,  and  give  to  it  a  slightly  countersunk  form.  All  parti- 
cles of  tooth  or  debris  should  now  be  carel\illy  removed  from  the 
cavity  by  the  syringe,  either  with  tepid  water  or  with  air;  the 
latter  only  where  the  tooth  has  been  kept  quite  dry  during  the 
process  of  excavation.  The  small  India-rubber  syringes  (Fig. 
150)  employed  for  tiiis  are  very  convenient,  as  they  necessitate 

Fia;.  150. 


Flexible  ludia-rubber  syringe. 

the  use  of  but  one  hand,  and  when  empty  refill  themselves  if 
the  nozzle  is  placed  below  the  surface  of  water  before  relaxation 
of  the  pressure  whicli  emptied  them. 

[Some  of  these,  however,  have  the  great  objection  that, 
when  they  stand  a  short  time  during  the  operation  about  half 
filled  with  warm  water,  the  air  witliin  them  becomes  saturated 


172    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

with  a  sulphurous  odor  that  makes  it  inexpressibly  disagreeable 
when  it  is  forced,  into  the  mouth.  Glass,  celluloid,  and  metal 
syringes  are  not  yet  surpassed  for  cleanliness,  and  the  trifling 
inconvenience  of  refilling  may  be  submitted  to,  as  it  may  be 
performed  wiiile  the  patient  is  expectorating.] 

The  next  consideration,  and  a  very  important  one,  if  this  has 
not  already  been  done,  will  be  the  protection  of  the  cavity  from 
access  of  moisture  during  the  insertion  of  the  filling.  It  may 
be  effected  by  placing  folds  of  blotting-paper  or  linen  cloth,  or 
the  folded  extremities  of  a  long  narrow  piece  of  diaper,  the 
older  and  softer  the  better,  on  the  one  side  between  the  tooth 
and  the  tongue,  and  on  the  other  between  the  tooth  and  the 
cheek,  and  retaining  the  same  by  the  finger  and  thumb  of  the 
left  hand  ;  or,  if  the  patient  be  more  than  ordinarily  intelligent 
and  tractable,  by  his  fore  and  middle  fingers  of  either  hand.  A 
variety  of  ingenious  instruments  termed  napkin-holders  have 
been  devised,  but  those  long  accustomed  to  this  method  of 
protection  will  mostly  prefer  the  cloth  or  paper  under  the 
control  of  their  own  hands.  If  the  operation  prove  a  long  one, 
and  especially  upon  teeth  of  the  lower  jaw.  the  saliva  will  be 
almost  certain  to  saturate  the  paper  or  cloth  and  find  its  way 
to  the  cavity.  To  obviate  this,  valuable  instruments,  termed 
saliva-ejectors,  have  been  introduced,  that  devised  by  Claude  S. 
Rogers  (Fig.  151)  being  probably  the  simplest,  if  not  quite  so 
effective  as  Fisk's  (Fig.  152).  Its  action  consists  in  creating  a 
vacuum  in  a  tube  by  the  pressure  of  water  flowing  down  the 
same,  entering  through  an  orifice  in  the  tube.  To  the  upper 
open  extremity  of  the  latter  an  elastic  tube,  terminating  in  a 
suitably  curved  nozzle,  is  attached,  which  the  patient  holds  in 
the  sulcus  in  his  mouth  between  the  tongue  and  lower  jaw.  The 
ingenious  device  of  the  rubber  coffer-dam,  for  which  we  are  in- 
debted to  Barnum,  an  American  practitioner,  if  less  agreeable  to 
the  patient,  certainly  achieves  in  a  most  perfect  manner  the 
object  contemplated.  Its  advantages  are  the  following,  viz.: 
It  being  placed  in  position  before  excavation  is  commenced,  the 
cavity  does  not  become  continually  fllled  with  saliva,  nor  the 
view  of  the  same  obscured,  nor  consequently  frequent  drying 
required,  the  dehris  being  blown  out  with  the  air  syringe.  It 
also  permits  the  patient  from  time  to  time  to  close  the  mouth 
and  to  swallow  the  saliva,  also  better  to  intimate  if  he  suffer 


TREATMENT  OF  DENTAL  CARIES. 


173 


pain,  etc.,  unduly.  By  its  use  both  hands  of  the  operator  are 
set  at  liberty.  The  operator  will  find  this  of  immense  advan- 
tage to  him  when  fiilling  teeth  in  positions  the  cavities  of  which 


Fig.  151. 


Fiff.  152. 


Sectional  view  of  Fisk's  ejector,  to  illustrate  the 
principle  upon  which  the  sucking  action  is  oljtained. 

can  be  seen  only  by  reflection. 
As  all  students  find  a  difficulty 
at  first  in  so  operating,  from 
their  movements  appearing  re- 
versed in  the  mirror  (Fig.  154), 
we  recommend  them  in  employ- 
ing it  to  bear  in  their  minds 
continually  the  position  of  the 
cavity  and  the  movements  neces- 
sary for  cutting  or  otherwise  its 
various  sides:  thej^  Avill  thus 
soon  forget  the  mirror  wdth  its 
deceptions  whilst  using  it.  As 
a  means  of  illuminating  a  cavity 
by  reflecting  the  light,  the  mir- 
ror is  also  a  very  valuable  instrument.  To  return  to  the  rubber- 
dam,  it  much  more  thoroughly  accomplishes  its  object  than  any 
other  plan,  even  keeping  away,  to  some  extent,  the  moist  air 


C.  S.  Rogers's  saliva  ejector. 


174        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

exhaled  from  the  lungs.    By  the  aid  of  clamps  it  can  be  applied 
in  almost  any  situation,  and  can  be  used,  and  to  the  comfort  of 


Fiff.  158. 


Fiff.  154. 


Silvered  j(laHs  iJioiiHi-iiiirror,  witli  l>all- 
aiid-8ocket  JMiiit   lor   placing  it  at  varii>us 
[Punch  for  tnaklog  holes  In  the  lubbcr  dam.]         unglex. 


TREATMENT  OF  DENTAL  CARIES.  175 

the  patient,  in  conjunction  with  the  saliva-punij).  As  tliis  ap- 
pliance has  become  so  important  a  feature  in  the  present  day, 
we  shall  describe  its  mode  of  application,  admitting  at  the  same 
time  that  in  common  with  many  of  the  older  practitioners  we 
have  used  it  much  less,  and  therefore  probably  can  apply  it 
with  less  dexterity,  than  man}'  of  our  juniors. 

The  material  employed  is  thin  sheet  India-ruljber :  in  sub- 
stance it  should  not  be  so  thick  as  to  occupy  much  space  when 
placed  between  the  teeth,  nor  so  thin  as  to  tear.  Of  this  a  size 
is  selected,  varying  according  to  the  position  of  the  tooth  to 
which  it  is  to  be  ap[)lied,  being  necessarily  larger  when  back 
teeth  are  included.  By  means  of  a  punch  (Fig.  153)  circular  holes 
are  cut  in  the  rubber:  thus,  if  we  were  about  to  apply  it,  say, 
to  a  central  incisor  of  the  upper  jaw,  we  should  make  three 
holes  so  as  to  include  the  tooth  in  question  and  its  two  neigh- 
bors, and  about  -jV  inch  in  diameter,  and  i  inch  from  each  other. 
For  bicuspids  we  should  do  much  the  same,  but  for  molars  we 
should  make  rather  larger  holes,  jV  ^'^ch,  and  at  rather  greater 
distances  from  each  other.  In  place  of  the  punch  we  may  draw 
the  rubber  tightly  over  the  extremity  of  the  steel  handle  of  an 
ordinary  excavator,  and  on  its  being  touched  a  short  distance 
from  the  extremity  with  a  penknife,  a  small  quite  round  disk 
will  fly  otf  from  it;  a  little  practice  will  enable  an  operator  to 
control  its  size.  The  next  proceeding  will  be,  to  place  the  dam 
in  position,  and  this  is  often  anything  but  easy  to  do.  It  is  best 
accomplished  by  holding  the  dam  by  the  thumbs  and  fingers  of 
both  hands,  the  hole  nearest  to  the  operator  being  stretched  over 
the  tooth  nearest  to  him  ;  then  the  next  in  order  is  in  like  man- 
ner included,  and,  finally,  the  third  tooth:  this  arrangement 
may,  however,  be  altered  as  convenience  dictates.  Where  the 
teeth  are  arranged  closely  together,  difficulty  will  be  experienced 
in  passing  the  rubber  between  them  :  to  facilitate  this  an  instru- 
ment (Fig.  155)  carrying  a  tensely  stretched  piece  of  silk  or 
thread  will  l)e  found  very  convenient,  and  the  thread  or  silk 
may  be  detached  and  employed  for  tying  round  the  teeth  adjoin- 
ing the  one  to  be  filled.  Floss  silk  rubbed  with  beeswax  will 
be  found  the  most  suitable  material  for  tying  with,  from  its 
smaller  liability  to  slip. 

In  cases  where  teeth  stand  alone,  or  where,  even  when  the 
dam  can  be  tied  on  to  adjoining  ones,  it  cannot  be  carried  so  far 


176    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

Fig.  156.] 


Fia:.  155 


[Fig.  157.] 


vy 


Fig.  LO.j.  Instrnmcnt  for  applying  tlio  rofTi'r-dam.  Silk  or  tliro.-ul  is  iiiiHMod  into  tlio  grooves  oT 
the  fork  end,  and  tightened  by  windins,'  it  idiind  tlie  steol  l)uttoii.  By  i:i<!iuis  of  the  tease  thread 
the  dam  can  he  prcHKed  between  the  toctli. 

[Fig.  156.  Clarap  forceps.     Bowman  Allen.] 

[Fig.  107.  Dr.  Teetj'  rul)l)fr.dam  clampM.] 


TREATMENT  OF  DENTAL  CARIES, 


177 


upon  the  neck  of  a  tooth  as  to  bring  it  beyond  tlie  radical  ex- 
tremity of  the  cavity,  the  clamp  may  be  employed  ;  thus,  if  we 


Fi£r.  158. 


Method  of  applyini,'  the  rubber-diim   as  secured   by  means  of  tlio  claiiiji.     In  tli is  arrangement 
(Elliott's)  the  clump  forceps  may  also  be  employed  in  the  place  of  Fig.  156. 


were  desirous  of  placing  the  dam  upon  an  npper  or  lower  third 
molar  standing  alone,  we  should  carry  the  clamp  to  the  tooth 
by  the  clamp  forceps.  This  ingenious  appliance  (Fig.  156),  when 
its  blades  are  inserted  into  the  clamp,  and  its  handles  pressed 
upon,  not  only  obtains  a  secure  hold  upon  the  clamp,  but  also 
distends  its  elastic  sides,  permitting  them  to  go  over  the  crown 
of  a  tooth  and  be  adjusted  to  its  neck,  when,  by  relaxation  of 
the  pressure,  the  blades  of  the  forceps  are  set  free,  and  the  clamp 
12 


178         MANUAL    OF    DENTAL    SDBGERY    AND    PATHOLOGY, 

Fiff. 159. 


The  rnbber-dam  and  clamp  in  situ. 


left  in  situ.  The  rubber  is  now  applied  over  both  clamp  and 
tooth,  a  little  additional  stretching  being  necessary  (Fig.  159), 
or  the  clamp  with  the  rubber  upon  it  (Fig.  158)  may  be  applied 

[Fig.  160. 


Dr.  Cogswell's  rnbber-dam  holders. 

Fis;.  161. 


UfliWfUl 

2 

Shape  for  rnbber-dam  to  admit  of  easy  respiration  and  to  make  two  triangular  pieces  of  one 

square.] 

at  the  same  time.    The  rubber-dam  being  arljusted,  its  projecting 
sides  are  drawn  to  the  cheek  of  the  patient  by  the  dam-holder, 


TREATMENT    OF    DENTAL    CARIES.  179 

an  elastic  band  which  passes  round  the  head,  and  terminates  at 
either  end  in  clips  which  grasp  the  rubber-dam  (Figs.  160  and  161). 
The  cavity  being  protected  from  access  of  moisture,  and 
carefully  dried,  if  necessary,  by  amadou,  thin  bibulous  paper,  or 
cotton  prepared  purposely,  the  operator  proceeds  to  insert  the 
tilling  which  he  has  selected.     Let  us  lirst  presume  this  to  be  a 


Owen's  deatal  table  with  three  trays  to  hold  instruments,  auJ  suitable  box  on  top  tray  for 

holding  gold. 

l^reparation  of  gutta-percha,  which,  as  employed  for  dental  pur- 
poses, is  a  compound  of  tiie  gum  [turified,  and  with  it  incor- 
porated some  fine  siliceous  or  hard  material,  giving  to  it  an 
increased  hardness  without  impairing  its  color,  which  should 
be  nearly  wdiite.  The  two  varieties  most  employed  are  Jacob's 
and  Hill's, — the  names  of  their  respective  introducers.  [In 
America,  S.  S.  White's  and  Johnston  Bros.  The  ordinary  pink 
gutta-percha  as  prepared  for  impressions,  and  for  trial  plates  also, 
has  its  use  and  its  friends.]  The  first,  an  English  preparation, 
is  certainly,  according  to  our  experience,  the  best  as  regards 
both  color  and  durability  ;  but  the  latter,  an  American  com- 
pound, is  more  easily  employed,  because  rendered  softer  and 
more  adhesive  at  a  lower  temperature.  [Great  stress  is  now  laid 
by  some  practitioners  u[)on  the  different  grades  of  plasticity  of 
different  preparations  of  gutta-percha.     They  commence  in  the 


180 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


deeper  portions  of  cavities  with  the  material  that  softens  at  the 
lowest  tenijierature,  in  order  to  avoi<l  irritation  of  the  teeth 
pulps,  finishing  by  overlaying  this  with  a  harder  grade  that 
requires  more  heat  to  render  it  plastic. 

This  material  is  now  highly  recommended  for  the  filling  of 
cavities  on  approximal  surfaces  of  teeth,  and  particularly  when 
the}-  run  to  the  cementum,  in  which  position  it  very  efl:ectually 
resists  the  action  of  the  acid  from  the  irritated  gum,  which  will 
attack  and  cause  oxychloride  fillings  to  be  washed  out  at  these 
points.  The  fillings,  when  deemed  desirable,  may  be  finished 
toward  the  masticating  surfaces  with  oxychloride,  to  give 
strength  to  weak  walls.] 

Some  of  either  variety  should  be  cut  into  pieces  smaller  than 
the  cavity  to  be  filled,  and  placed  on  a  small,  but  steady  table, 
Fig.  162,  or  movable  bracket  support.  Fig.  163,  placed  near  to, 


[Fig.  163. 


Tl,.'  M-.n-l-ui, 


and  al)out  the  same  level  as,  the  patient's  mouth,  on  which  should 
be  arranged  all  the  instruments  and  appliances  that  the  operator 
will,  or  will  be  likely  to,  require  during  the  operation. 
Amongst  these  a  spirit   Uunp  will   be  requisite;  and,  all  being 


TREATMENT  OF  DENTAL  CARIES, 


181 


ready,  he   should  warm  the  point  of  a  small   steel  instrument 
bent  at  a  suitable  angle,  and  covered  at  a  short  distance  from 

[Fig.  1G4. 


Dr.  C.  F.  AUau'.s  patcorii  of  table  for  the  bracket.] 

the  extremity  with  some  non-conductins;  substance,  to  prevent 
the  lips  from  being  burned  should  it  chance  to  touch  them,  and 
thus  attach  it  to  a  piece  of  the  gutta-percha.  These  instruments 
are  conveniently  formed  out  of  broken  excavators,  of  which  the 
operator  has  generally  but  too  large  a  stock,  and  with  these 
the  gutta-percha  is  carried  to  the  flame  of  the  spirit-lamp  and 
passed  just  over  or  through  it,  backwards  and  forwards,  long 
enough  to  soften  it,  but  before  any  smoke  is  seen  to  ascend  from 
it.  At  a  less  degree  of  heating  it  is  not  sufficiently  soft  or 
adhesive:  at  a  greater,  it  will  burn,  and  its  surface  be  injured 
and  powdery.  A  more  suitable  appliance  than  the  spirit-lamp 
for  heating  the  gutta-percha  is  a  tray  or  dish  surrounded  with 
hot  water,  Fig.  1G6,  as  the  material  is  more  evenly  heated  and 

Fi?.  165. 


Houghton's  steel  spatula  of  suitable  form  for  finishing  off  gutta-percha  and  amalgam  fillings. 

in  no  danger  of  being  burnt.  When  thus  lieated  to  the  right 
degree  it  is  carried  to  the  cavity  and  attached  to  that  side  or 
part  of  it  which  is  the  least  accessible,  and  this  is  often  accele- 
rated by  employment  of  a  second  instrument  not  heated.  The 
heat  on  contact  may  cause  some  pain,  but  seldom  of  lono;  dura- 
tion, and  the  second  and  succeeding  portions,  when  attached  to 


182 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY 


the  first,  which  should  adhere  firmly,  cause  generally  much  less 
puin.  In  this  way  the  cavity  is  filled,  or  a  little  over-filled, 
when  the  superfluous  portion  may  be  cut  off  with  a  thin  spatula 
of  steel,  or,  better  still,  of  platina,  see  Figs.  165,  167,  heated 
nearly  to  redness,  and  the  surface  smoothed  over  with  a  polished 
burnisher  (see  Fig.  169). 

[Fig.  166. 


Prof.  J.  F.  Flagg's  lamp  and  wator-bath.] 


Gutta-percha  filling  possesses  the  following  recommendations. 
It  is  a[)plied  without  much  difficulty,  becoming  readily  softened 
by  heat,  and  very  soon  hard  again;  it  adheres  to  a  tooth  with 
some  force,  and  may  therefore  be  employed  when  a  cavity  is 


TREATMENT    OF    DENTAL    CARIES.  183 

shallow  and  l)a(lly  adapted  for  retention;  it  requires  but  little 
pressure,  a  qaalificution  where  the  walls  of  a  tootli  are  slender; 
it  is,  probably  owing  to  its  vegetable  nature,  the  least  likely  to 
cause  irritation  of  all  the  substances  that  we  so  employ  ;  it 
resists  moderately  well  such  acids  and  alkalies,  also  such  tem- 
perature, as  may  be  met  with  in  the  mouth  ;  and,  lastly,  it  is  of 
excellent  color,  very  fairly  resembling  the  enamel  of  teeth.  Its 
great  disadvantage  is,  however,  a  serious  one,  viz.,  its  insuffi- 
cient hardness  to  resist  the  force  of  mastication  ;  and  it  soon 
wears  away,  and  is  also  pressed  away  from  surfaces  exposed  to 
friction.  In  time  also  it  appears  to  break  up  and  become  some- 
what permeable  to  fluids,  and  therefore  to  emit  an  ott'ensive 
smell  ;  still  we  have  in  favorable  cases  seen  it  [)reserving  a  tooth 
after  eleven,  and  even  twelve,  years  without  reapplication.  Its 
employment  will  be  found  most  valuable  in  cavities  situated  at 
the  necks  of  teeth,  especially  when  extending  under  the  gum. 
[The  pain  from  the  heat  may  be  almost  entirely  avoided  by 
using  at  first  thin  layers  or  disks  of  easily  softened  gutta-percha 
upon  the  floor  of  the  cavity.  The  finishing  with  a  warmed 
instrument  must  be  cautiouslj-  done,  lest  the  gum  or  the  filling 
be  burned.  It  is  better  to  pass  the  w^armed  instrument  but 
once  after  willing,  and  always  toward  the  edges  of  the  filling. 
Chloroform  used  upon  a  pellet  of  cotton  or  a  piece  of  common 
lamp  wick,  makes  a  nice-looking  finish,  but  it  seems  to  soften 
the  surface  and  dissolve  oft'  the  gutta-percha,  rendering  it  less 
likely  to  retain  its  proper  contour.  The  greatest  difficulty  in 
these  fillings  is  the  danger  of  moisture,  blood,  etc.,  working  in 
before  the  filling  is  completed,  as  they  will  prevent  the  adhesion 
of  the  gutta-percha  to  the  teeth  or  the  cohesion  of  one  portion 
of  layer  to  another.] 

Zinc  oxychloride,  vended  under  tlie  absurd  names  of  osteo- 
plastic, OS-artificial,  artificial  enamel,  etc.,  are  supplied  by  various 
makers  in  the  form  of  zinc  oxide  in  powder,  and  the  zinc 
chloride  in  fluid:  in  many  the  former  is  mixed  with  some  finely 
powdered  siliceous  material,  to  increase  the  hardness,  whilst, 
the  latter  containing  some  water,  a  combination  is  formed  re- 
sulting in  a  cement,  which,  like  others  of  a  similar  class,  takes 
up  some  of  the  water  as  a  base,  and  thus  forms  hyd rated  oxy- 
chlorides  of  the  metal. 

In  employing  this  filling,  a  little  of  the  powder  is  placed  on 


184 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY, 


a  glass  or  porcelain  slab  with  a  drop  or  two  of  the  liquid,  and 
the  two  mixed  into  a  thick  paste  with  the  platiua  or  an  ivory 
spatula,  and  conveyed  by  the  same  to  the  cavity,  previously 
dried,  and  is  carefully  worked  against  its  sides,  to  ensure  per- 


Fiff.  167. 


JIoAdiuns's  combined  spatula  and  stopper,  constructed  of  hard  platina  and  mounted  in  ivory, 
suitable  for  oxychloride  and  pyrophosphate  of  zinc  fillings. 

feet  adaptation  and  the  exclusion  of  air-spaces;  the  later  por- 
tions added  may  with  advantage  be  of  thicker  consistency. 
The  tilling,  if  fresh,  sets  in  a  few  minutes,  but  it  may  be  well  to 
coat  it  with  varnish,  or  gutta-percha  dissolved  in  chloroform, 
before  permitting  the  moisture  of  the  mouth  to  have  access  to 
it.  After  it  has  properly  set,  rubbing  its  surface  with  some 
highly  polished  substance,  such  as  agate,  for  instance  (Fig.  168), 

Fis?.  108. 


Eowney's  agate  burnisher  for  polishing  and  hardening,'  the  surface  of  fillings. 

will,  by  lessening  its  porosity,  increase  its  resisting  powers  in 
the  mouth. 

[The  burnisher  may  be  warmed,  and  thus  hasten  the  setting 
of  the  oxychloride,  with  seeming  gain  of  liardness.  A  patent 
has  been  taken  out  for  the  use  of  instruments  made  of  talc,  by 
which  the  warming  may  be  accomplished  and  the  surface  of  the 
filling  polished,  and  thus  rendered  somewhat  less  likely  to  per- 
mit water  to  soak  into  the  mass.] 

The  advantages  possessed  by  the  zinc  oxj^chloride  are:  Ease 
in  application,  ra[)idity  in  setting,  a  considerable  degree  of  hard- 
ness when  set,  attachment  to  surfaces  when  dry  with  considerable 
force,  and  therefore  great  suitability  for  shallow  cavities  and 
cavities  with  very  fragile  walls,  and  a  color,  though  not  equal 
in  this  respect  to  gutta-percha,  still  nearer  to  that  of  the  teeth 
tiian  many  otlier  substances  employed.  Its  disqualification,  and 
that  a  most  im[)ortant  one,  is,  that  it  is  acted  on  by  weak  acid 


TREATMENT    OF    DENTAL    CARIES.  185 

and  alkaline  solutions,  and  even,  to  a  minute  extent,  by  pure 
water,  hence  it  cannot  be  relied  on  as  a  permanent  filling, 
yielding,  in  contrast  to  gutta-percha,  the  most  unfavorable 
results  when  applied  at  or  near  to  the  margin  of  the  gum.  It 
also  produces  considerable  pain  when  applied  to  very  sensitive 
dentine;  but  this  disadvantage  is  more  than  counterbalanced 
by  its  power  of  destroying  such  sensibility,  as  we  shall  jjres- 
ently  show.  It  would  be  difficult  and  unsafe  to  make  any 
statement  as  to  the  varieties  which  are  most  to  be  depended 
upon,  further  than  that  in  our  hands  the  compounds  of  Fran- 
zelius  and  Ash  have,  on  the  whole,  yielded  the  best  results. 
No  doubt,  in  time,  these  compounds  will  be  rendered  more 
perfect. 

Closely  resembling  the  oxychloride  in  character  is  the  pyro- 
phosphate of  zinc,  vended  like  the  former,  but  having  the  pyro- 
phosphoric  acid  in  crystals.  Tiierefore,  when  it  is  eni})loyed, 
the  crystals  must  be  melted,  which  is  best  done  in  a  platina  or 
porcelain  spoon  held  over  a  spirit-lamp, ebullition  being  avoided; 
and,  when  fluid,  or  reduced  to  about  the  consistency  of  glycerine, 
it  is  dro[)ped  on  the  slab  mentioned,  which,  in  cold  weather  at 
least,  should  be  previously  warmed.  It  mixes  less  readily  than 
does  the  oxychloride,  and,  if  it  be  mixed  too  thickly,  a  crumb- 
ling mass  results,  or,  if  too  thinly,  a  sticky,  unworkable  one: 
the  proper  combination  will  be,  when  it  can  be  rolled  between 
the  finger  and  thumb  without  sticking  to  them  or  breaking  to 
pieces.  As  it  sets  very  rai>idl3^,  no  time  must  be  lost  in  con- 
veying it  to  the  cavity,  and  its  introduction  into  the  cavity  is 
facilitated  by  the  pi'essure  of  a  highly  polished  steel  burnisher: 
a  platina  one  would  no  doubt  be  preferable.  Its  qualifications 
and  disqualifications  are  so  similar  to  the  oxychloride  above 
mentioned,  that  we  need  only  say  that  it  differs  from  it  in 
proving  far  more  durable,  especially  when  applied  at  the  necks 
of  the  teeth.  With  both  these,  compounds  it  is  essential  that 
they  should  be  employed  when  recently  made;  exposure  to  air, 
especially  in  the  case  of  the  pyrophosphates,  causing  considerable 
deterioration.  It  is  unfortunate,  therefore,  that  they  are  not 
vended  in  smaller  quantities  and  in  hermetically  sealed  vessels. 
The  pyrophosphate,  to  which  our  remarks  are  referable,  is  that 
sold  as  Pulson's:  other  varieties  may  require  somewhat  modified 
manipulation. 


18(3  MANUAL    OF    DENTAL    SURGKRY    AND    PATHOLOGY. 

[Fla2fg's,Gnillois',Weston's,  acme  and  agatecement,  and  cement 
plonibe  have  their  friends  in  this  country,  and  it  seems  that, 
although  some  may  be  better  capable  of  resisting  solution  in 
certain  mouths  than  others,  doubtless  one  of  the  principal  causes 
of  ditierence  of  success,  resides  in  the  variation  of  manner  of 
mixing  and  inserting.  Although  at  first  sight  these  plastics 
would  seem  to  be  readily  managed,  it  is  now  conceded  that 
great  exf)edition  and  expertness  are  demanded  for  thorough 
mixing  and  use  before  setting  has  progressed  so  far  as  to  impair 
their  value.'] 

Of  the  alloys  of  mercury  with  other  metals,  termed  amal- 
gams, those  which  become  hard  after  mixture  have  long  enjoyed 
a  reputation  amongst  the  substances  employed  in  tilling  teeth. 
As  they  possess  no  direct  property  of  adhesion  to  the  walls  of  a 
tooth,  it  is  necessary,  in  preparing  a  cavitj'-  for  their  reception, 
that  there  be  some  undercutting,  or  dove- tailing,  to  retain  them. 
[Sharp  angles,  grooves,  undercuts,  and  pits,  are  contraindicated 
from  the  well-known  tendency  of  the  amalgam  to  assume  the 
spheroidal  shape.^]  Two  classes  of  these  compounds  apparently 
exist,  viz.,  where  the  combination  is  a  binary  one,  and  appears 
something  more  than  a  mere  mixture  or  solution  of  one  metal 
in  the  other,  heat  being  evolved  in  the  union;  and  the  result  is, 
probably,  a  definite  chemical  compound,  dissolved  in  either 
metal  which  may  be  in  excess  of  atomic  quantity — analogous, 
probably, to  the  mixtures  of  sulphuric  acid  in  water — at  all  events, 
the  resulting  alloys,  as  in  the  cases  of  mercury  and  palladium, 
or  silver,  or  copper,  are  admitted  to  undergo  less  change  in 
bulk  after  their  mixture  and  application  than  do  any  of  the 
other  compounds  consisting  of  more  than  two  metals  and  which 
comprise  the  second  class.  Unfortunately,  the  first  class  pos- 
sesses one  great  drawback,  viz.,  unsuitable  color;  and  the  silver 
and  cop[)er  compouuds  the  additional  one  of  staining  the  teeth, 
the  silver  a  bluish-black  color,  and  the  copper  a  greenish  ;  of  the 
second  class,  some  are  now  prepared  which,  when  properly 
manipulated,  keep  their  white  silvery  color  for  many  j-ears. 

In  applying  the  amalgams,  certain  precautions  are  necessary, 
according  to  the  description  employed  ;  thus,  with  palladium, 
its  compound  sets  very  rapidly,  so  much  so  that  we  have  found 

['  See  Fliigg's  "Plastics  and  Plastic  Filling."] 
[2  Seepage  191.] 


TREATMENT  OF  DENTAL  CARIES. 


187 


some  specimens,  and  probably  the  purest,  almost  useless ;  also, 
when  mixed  in  largish  quantities  at  a  time,  say  enough  for  a 


Fiff.  1G9. 


i 


r 


Polished  steel  burnishers  of  various  forms. 


Four  useful  forms  of  amalgam  stoppers. 


188         MANUAL    OF    DEXTAL    SURGERY    AND    PATHOLOGY. 

good-sized  cavity,  it  evolves  so  much  heat  as  to  explode  with 
emission  of  light.  About  as  much  mercury  as  would  fill  the 
cavity  to  be  treated  is  placed  in  the  palm  of  the  hand,  and  the 
palladium  powder  very  gradually  added.  It  requires  some  care- 
ful rubbing  with  the  forefinger  before  the  two  become  incorpo- 
rated, when  it  should  be  divided  into  smallish  pellets,  and  these 
rapidly  carried,  one  after  another,  to  the  cavity,  each  piece 
being  well  compressed  and  rubbed  into  the  inequalities  of  its 
walls  by  a  burnishing  or  compressing  instrument,  and  with  a 
rotary  movement  of  the  hand.  This  is  continued  until  the 
cavity  is  quite  filled,  or  even,  if  necessary,  to  some  slight  extent 
built  out,  the  surfiice  being  rendered  smooth  and  polished  with 
the  burnisher  until  it  has  quite  set,  which  is  generally  in  a 
verj'  little,  too  short  a  time.  This  is  probably  the  most  dur- 
able of  all  the  amalgams,  but  the  most  difiicult  to  manipulate. 
Its  surface  changes  to  a  black  color,  but,  as' a  rule,  it  does  not 
stain  the  structure  of  the  tooth.  The  circumstance  of  its  set- 
ting so  soon  has  one  advantage,  viz.,  that  the  patient  is  less  liable 
to  displace  it  at  the  next  meal.  The  silver  compound  is  prob- 
ably quite  equal  in  durability  to  the  palladium,  but  its  staining 
and  discoloring  properties  are  so  objectionable  that  it  is  very 
rarely  employed.  It  sets  almost  as  rapidly  as  the  last  named, 
and  must,  therefore,  be  worked  with  the  same  x>i'ecautions. 
Some  experiments  we  have  lately  made  with  this  compound 
entitle  it,  we  think,  to  be  more  employed  than  it  has  been,  and 
especially  in  cases  where  the  cavity  can  be  partially  lined  with 
the  pyrophosphate  cement. 

The  copper  amalgam*  is  supplied  in  a  difterent  form  from  any 
other,  viz.,  copper  already  in  combination  with  mercury,  and  is 
commonly  known  as  Sulivan's,  the  name  of  a  maker  who  has 
long  prepared  it. 

It  is  probably  the  easiest  to  employ  of  all  amalgams.  One  of 
the  little  egg-shaped  pieces,  in  which  form  it  is  vended,  is  placed 

'  The  compound  now  generally  supplied  under  tbe  name  of  Sulivan's  is,  we 
believe,  prepared  1)y  precipitating  copper  from  a  solution  of  the  sulphate,  with 
mercury  at  the  bottom  of  the  vessel  that  contains  it,  by  means  of  stirring  the 
fluid  with  a  piece  of  zinc.  A  much  better  preparation  is  that  obtained  by  sub- 
stituting iron  for  zinc.  The  latter  as  so  prepared  was  employed  many  years 
ago,  and  we  occasionally  now  recognize  it  by  a  coppery  lustre  on  portions  most 
subjected  to  friction  ;  it  is,  wc  believe,  harder  and  more  durable  than  the  zinc- 
prepared  material. 


TREATMENT  OF  DENTAL  CARIES, 


189 


in  a  small  iron  spoon  or  ladle  (Fig.  171),  and  orently  lieated  over 
the  flame  of  a  spirit-lamp,  until   minute  globules  of   mercury 


Fis.  171. 


Iron  spoon  or  ladle  with  wooden  handle  for  heating,  over  a  spirit-lamp,  the  copper  (Sulivan's) 

amalgam. 

exude  upon  its  surface,  with  generally  a  slight  hissing  noise;  it 
18  tiien  transferred  to  a  glass  or  agate  mortar  (Fig.  172),  broken 
up,  and  rubbed  into  a  smooth  paste;  it  should  then  be  well 
washed  with  a  weak  solution  of  sul})buric  acid;  some  recommend 

Fi?.  173. 


Pestle  and  mortar  for  breaking  up  the  copper  amalgam  when  heated.  For  this  purpose  thev 
should  be  constructed  of  either  agate  or  glass,  as  the  compound  adheres  to  Wedgwood's  com- 
position. 

soap  and  water,  until  no  longer  any  black  fluid  can  be  obtained 
from  it,  when  the  acid  or  soap  should  be  removed  with  clean 
water,  and  if  the  latter  quite  dissolved  out  with  alcohol,  and 
the  amalgam  thoroughly  dried  between  folds  of  soft  linen. 

[It  has  been  some  years  since  well-known  amalgam  workers 
have  objected  to  washing  as  likely  to  make  a  less  perfect 
filling,  from  the  impossibility  of  removing  the  water  or  fluid 
in  time  to  employ  the  amalgam.  It  is  even  claimed  that  the 
discoloration  under  an  amalgam  tilling,  is  in  a  measure  preserva- 
tive, tending  to  till  up  the  dentinal  tubuli ;  particularly  is  stress 
laid  upon  this  in  very  soft  teeth  with  marked  porosity  of  the 
dentine.] 

A  quantity  of  mercury  may  generally,  after  the  amalgam  is 
dried,  be  squeezed  out  through  wash-leather,  leaving  it  in  an 
almost  powdery  condition,  which,  on  being  rubbed  in  the  palm 
of  the  hand,  will  soon  become  coherent  and  soft,  when  still  more 
mercury  may  be  squeezed  out.     The  drier  it  can  be  employed 


100 


MANUAL   OF    DENTAL   SURGERY    AND    PATHOLOGY. 


the  better,  provided  it  will  cohere  in  the  cavity  of  the  tooth, 
Avhicli  cohesion  will  be  favored  by  the  warmth  of  the  mouth, 
and  this  also  admits  of  drier  portions  being  added  to  those  first 
employed.  The  patient  should  be  strictly  enjoined  to  avoid  eat- 
ing upon  it  for  several  hours,  or  be  restricted  to  a  soup  diet  for 
that  day.  Under  the  above-mentioned  conditions  a  moderately 
hard  and  durable  stopping  can  generally  be  effected  ;  but  its 
black  color,  together  with  staining  of  the  tooth,  are  objections 
to  its  employment ;  doubtless  it  will  always  be  useful  for  certain 
cases,  such  as  the  almost  inaccessible  cavities  near  to  the  gum 
between  back  teeth. 

Those  varieties  in  which  the  compounds  are  apparently  more 
of  the  nature  of  mixtures  than  the  foregoing,  are 
generally  composed  of  silver  and  tin,  to  which  ma}'' 
be  added  small  quantities  of  either  gold  or  platina, 
or  both,^  mixed  in  certain  proportions  by  the  various 
makers,  by  whose  names  they  are  designated, 
melted  into  ino-ots,  and  then  cut  into  the  conve- 
nient  form  of  filings.  Their  mode  of  application 
is  as  follows:  a  small  quantity  of  mercury  should 
be  shaken  from  the  drop  bottle  into  the  palm  of  the 
left  hand,  and  to  this  is  added  by  degrees  the  til- 
ings, which  are  thus  dissolved  in  the  former  until 
the  mass  is  scarcely  coherent ;  it  should  then  be 
transferred  to  the  mortar  and  thoroughly  mixed 
The  moicury    j^,-,(j  incorporated  ;  it  may  then  be  again  rubbed  in 

drop  liottle  from  '-  ,  ,   •■  •  t     i 

which  the  metal    the  palm  of  the  hand  until  it  exhibits  a  slight  con- 


Fisr.  173. 


can  be    shaken 
in  fine  globules. 


sistency 


'  One  formula  is,  gold  one  part,  silver  three  parts,  tin  two  parts. 

2  T.  Fletcher,  of  Warrington,  has  introduced  a  very  perfect  and  efficient 

Fiff.  174. 


Balance  for  weighing  out  Fletcher's  filiiji^s  and  mercury  in  proper  proportions.  The  arrange- 
ment admilH  of  two  varieties  be'n^.'  woiglied  ;  tlius  mercury  Is  put  into  the  most  distant  of  tlie  two 
cups  and  counterbalanced  by  filings  at  the  opposite  extremity  for  his  platinum  amalgam,  but  put 
Into  the  other  cnp  and  In  like  manner  counterbalanced  for  liis  e.xtra  plastic  amalgam, 

nietl)od  of  manipulating  his  amalgam  (plafina  and  gold  alloy).     By  a  simple 
form  of  balance,  the  right  proportions  of  filings  and  mercury  are  obtained,  and 


TREATMENT  OF  DENTAL  CARIES, 


191 


This  mixture  is  can-led  in  small  portions  to  the  cavity  of  the 
tooth,  where  it  must  be  patiently  rubbed  and  pressed,  and  any 


Fia;.  175. 


Fis;.  176. 


Fletcher's  mixing-tabe  for  shakiiiir  together  the  filings  and  the  mcrcnry. 

appearance  of  free  mercury  be  met  by  the  addition  of  portions 
containing  smaller  and  smaller  quantities  of  that  metal,  keeping 
np  the  pressing  and  rubbing  until  indications 
of  setting  are  becoming  evident;  and  this  pro- 
cess may  be  necessary  for  a  considerable  time, 
its  object  being  to  avoid  that  condition  which 
fluid  and  semifluid  bodies  have  a  tendency,  by 
attraction  of  their  particles,  to  assume,  viz.,  the 
spheroidal  form,  which  we  believe  we  were  the 
first  to  point  out  in  regard  to  amalgams,  as  one 
cause  of  their  separation  from  the  margins  of  a 
cavity.  To  ensure  a  more  perfect  result  in 
regard  to  both  durability  and  appearance,  all 
amalgam  fillings  after  a  few  days  should  have  Fletcher's  mortar 
their  surfaces  carefully  polished.     It  often  hap-     andpianger  for  com- 

,  .  ,   .  ,      .  .  pressing  his  platiDum 

pens  that  in  smoothing  over  their  summits  some    amalgam  into  disks 
of  the  compound  is  spread  over  the  surrounding    p"'"'  '°  insertion  in 

^  _      ^  "       the  tooth. 

tooth,  and  this  thin  layer  breaks  aAvay,  leaving 
slight  irregularity  and  imperfection  ;  if  filing  be  not  feasible, 
such  superfluous  portions  may  be  wiped  off,  when  the  fillino-  is 
completed,  with  a  piece  of  soft  amadou. 

As  it  is  very  difficult  to  carry  out  an  amalgam  filling  in  a 
powdery  condition,  with  a  cavity  in  which  one  of  the  sides  is 
wanting,  considerable  assistance  is  attbrded  by  the  emjiloyment 


these  are  incorporated  bj-  agitation  in  a  test-tube  until  thoroughly  mixed,  wlien 
the  powderj'^  mass  is  transferred  to  an  ivory  compressor,  -nhich  reduces  it  into 
small  cakes  of  cheese-like  form  :  these  are  divided  into  smaller  fragments  and 
introduced  into  the  cavity  of  a  tooth,  and  worked  into  a  consistent  mass  by  a 
broad  plugger  pressed  upon  by  the  hand  or  the  action  of  a  mullet.  Ot"  both  the 
preparation  and  the  mode  of  its  manipulation  we  can  speak  most  highly. 


192 


MANUAL  OF  DENTAL  SUKGERT  AND  PATHOLOGY. 


of  a  thin  metal  clamp  applied  round  the  tooth  so  as  to  supply 
during  the  process  a  temporary  wall,  and  which  is  removed 
when  tlie  filling  is  completed. 

In  cases  where  it  is  desired  to  huild  up  the  lost  crown  of  a 
tooth  upon  a  surface  almost  level  with  the  gum,  and  which  will 
alibrd  a  vevy  uncertain  hold  for  the  amalgam,  we  may  greatly 


Ficr.  177. 


Fis.  178. 


Thin  metal  clamp  (Pinnev's)  suit- 
able for  passing  round  a  tooth  and 
forming  a  temporary  wall  for  snstain- 
ing  an  amalgam  during  the  process  of 
filling. 


An  arrangement  for  giving  support  to  an  amalgam  fill 
ing  upon  an  almost  flat  surface  by  screwing  pieces  of  gold 
wire  into  the  substance  of  the  tooth  or  its  fangs.  The 
free  extremity  of  the  wire  is  sawn,  and  the  sections  can 
be  bent  outwards  after  the  insertion  of  the  wire. 


increase  the  latter  hy  screwing  pieces  of  gold  wire  into  the  root- 
cavities  ;  the  projecting  portions  of  the  wire  being  previously 
sawn  across  with  a  hair  saw,  they  may  be  opened  and  pressed 
outwards  like  the  petals  of  a  flower  (Fig.  178).  As  some  practi- 
tioners have  believed  that  they  have  sutfered  from  mixing  these 
mercurial  compounds  in  the  hand,  the  mortar  may  be  employed 
throughout. 

Some  few  general  precautions  in  regard  to  amalgam  fillings 
may  here  be  insisted  on;  thus,  they  should  never  be  placed  in 
cavities  where  pulps  are  almost  exposed,  without  some  inter- 
vening body  of  less  heat-conducting  properties.  They  are  less 
suited  f(U'  the  teeth  of  young  people,  such,  for  instance,  as  have 
large  cavities  in  the  first  permanent  molars  at  the  ages,  say,  of 
seven  to  fourteen  ;  in  this,  as  in  the  former  case,  there  is  great 
liability  to  death  of  the  pulp.  They  are  never  to  be  inserted, 
without  special  precautions,  upon  surfaces  of  sensitive  teeth, 
where  they  may  come  into  contact  with  the  gold  clasps  of  arti- 
ficial dentures,  as  severe  pain  will  be  experienced  bj''  an  electrical 
action  set  up  by  the  two  metals  coming  in  contact.  Near  the 
front  of  the  mouth  they  must  be  used,  if  at  all,  very  sparingly ; 
but  we  cannot  lay  down  the  law  that  the  whitest  varieties  shall 
never  be  inserted  into  the  front  teeth.    We  have  even  seen  palla- 


TREATMENT  OF  DENTAL  CARIES.  19-3 

(lium  inserted  in  the  back  portions  of  front  teeth,  the  presence 
of  which  we  shouhl  never  have  detected  but  for  tlie  mouth-mir- 
ror; but  here  the  thickness  of  tooth-substance  between  the  cavity 
and  the  surface  was  considerable.  We  have  met  with  some 
varieties  of  palladium  which  have  stained  the  teeth  quite  as 
badly  as  the  copper  compound.^ 

The  next  and  last  of  the  materials  which  we  shall  describe  as 
used  for  filling  teeth  are  the  metals  in  their  unalloyed  state; 
they  are  employed  either  in  the  form  of  thin  sheets,  or  in  a 
finely  precipitated  condition,  but  much  more  commonl}'  in  the 
former.  Those  thus  used  are  gold,  platina,  and  tin,  of  which 
gold  only  has  been  as  yet  supplied  in  the  precipitated  form.^ 

Of  all  the  materials  employed  in  filling  teeth,  gold  has  cer- 
tainly enjoyed  the  greatest  reputation,  but  we  fear  that  its  popu- 
larity has  not  been  wholly  free  from  an  element  of  vulgar  pre- 
judice, at  least  on  the  part  of  some  patients.  However  this  may 
be,  there  can  be  no  doubt  but  that  a  metal  so  little  afltected  by 
chemical  reagents  is  admirably  adapted  for  occupying  a  position 
in  the  oral  cavity.  The  modes  of  its  application  are  by  no  means 
easy, and  undoubtedly  require  a  long  and  careful  training  before 
excellence  can  be  attained,  such  as,  it  must  be  confessed,  our 
American  brethren  have  exhibited.  To  build  up,  as  it  were, 
from  little  more  than  a  fragment  of  a  tooth,  a  golden  crown  of 
corresponding  anatomical  form  to  the  structure  lost,  requires  no 
little  skill  and  experience  on  the  part  of  the  operator,  and  must 
be  met  with  an  amount  of  patience  and  endurance  on  the  part 
of  the  patient  not  always  to  be  obtained,  even  at  the  prospect 
of  such  a  reward.  [Many  cases  of  so-called  building  up  of  gold 
upon  the  teeth  have  l)een  conducted  with  such  disregard  of  the 
patient's  general  health  as  to  produce  injury  to  the  whole  system.] 

'  Sorae  years  ago  a  readily  fusible  metallic  compound  was  occasionally  em- 
ployed for  filling  purposes  ;  it  appeared  to  make  a  durable  stopping  of  good 
color,  but  the  heat  necessary  to  soften  it  was  more  than  could  be  generally 
borne,  even  in  dead  teeth. 

2  Within  the  last  two  years  a  preparation  has  been  introduced,  termed  Sladen's 
compound,  which  consists  of  an  amalgam  in  a  ver}'  finely  divided  condition,  and 
which  is  consolidated  by  pressure  in  much  the  same  way  as  precipitated  gold, 
to  be  spoken  of  presently.  It  seems  to  be  capable  of  making  a  stopping  of  good 
color,  with  little  liability  to  change  its  dimensions,  but  sufficient  time  has  not 
yet  elapsed  to  enable  us  to  speak  with  any  confidence  in  regard  to  its  true 
value. 

13 


194 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


As  the  operations  of  filling  teeth  with  gold,  especially  when  em- 
ployed in  the  cohesive  form,  are  lengthy  and  fatiguing  ones,  we 
counsel  the  heginner  to  make  early  attempts  to  conduct  them 
in  the  sitting  posture,  and  to  this  end  we  believe  he  will  find  no 
appliances  so  valuable  as  a  Wilkerson's  operating  chair  and  a 
Lyon's  stool.     The  numerous  movements  of  the  former,  so  easily 

Fig.  179. 


The  Wilkorsoii  operating  chair.  The  various  movements  of  the  seat,  back,  head-piece,  foot- 
hoard,  and  of  the  whole  chair  itself  upon  its  pedestal,  are  as  perfect  as  it  is  possible  to  imagine, 
and  are  carried  out  with  a  patient  seated,  rapidly  and  with  a  very  small  amount  of  force. 


effected  with  the  patient  in  the  cliair,  and  the  suitable  angles 
at  which  the  latter  can  be  placed,  are  only  fully  a[)i)reciated  by 
those  who  have  learned  to  operate  in  a  sitting  posture. 

The  gold,  prepared  in  sheets  or  leaves,  is  technically  termed 
foil,  each  sheet  being  usually  about  four  inches  square,  and  vary- 
ing in  weight  from  2  up  to  240  grains;  of  late  years  the  makers 


TREATMENT  OF  DENTAL  CARIES. 


195 


have     conveniently    attached    the  ■'^^"j.!^" 

number  to  each  represented  by  their  V^ 

weight  in  grains.     In  the  employ-  •       ""~~"^ 

ment  of  difierent  numbers  there  is 
much  variety  of  opinion,  some  pre- 
ferring the  lower  and  some  the 
higher ;  if  there  be  any  rule,  it 
would  be  the  obvious  one  of  the 
former  being  selected  for  small  and 
the  latter  for  large  cavities.  Which- 
ever be  selected,  one  rule  does  pre- 
vail, and  that  is,  to  endeavor  to 
insert  the  foil  in  folds  parallel  to 
the  side  walls  of  the  cavity,  i.  e., 
vertically  to  the  base  and  orifice  of 
the  cavity,  as  there  will  then  be 
less  liability  in  the  metal  to  flake 

•  /->  n    •         ^  Lion's  adjustable  stool  ;  the  seat  fiiu 

oil   than    if   some    of    its  layers  were       be  raised   to  any  necessary  height  and 

arranged   parallel    to   the    bottom     ^^i^o  placed  at  various  angles. 

and  orifice  of  the  cavity:  the  following  methods  to  this  end  are 

adopted : — 

1.  By  tape  or  ribbon. — A  sheet,  say,  of  No.  5  foil  is  divided 
by  a  long  clean  pair  of  scissors  (Fig.  181)  into  three  or  four 
even  strips,  and  each  of  these  folded  n{)on  itself  until  the  re- 
duced width  is  about  the  diameter  of  the  cavity  to  be  filled. 

Fiff.  181. 


Scissors  suitable  for  dividing  the  sheets  of  gold  and  other  foil. 


The  folding  may  be  best  accomplished  with  a  gilder's  knife  (Fig. 
182),  as  the  ribbon  or  tape  so  formed  will  be  more  uniform  in 
size,  and  less  fingered,  than  if  folded  by  the  hand.  If  the  cavit}'- 
be  protected  from  moisture  by  a  napkin  kept  in  position  by  the 
forefinger  and  thumb  of  the  left  hand,  one  end  of  the  tape  is 


196        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

seized  by  the  foil  forceps  (Fig.  183)  or  attached  to  the  end  of  a 
serrated-pointed  plugger,  by  pressing  on  the  foil  laid  upon  cloth 
or  velvet,  and  so  conveyed  to  the  cavitj^  where  it  is  best  to  com- 
mence at  the  most  distant  or  most  inaccessible  part.    In  the  case 

Fiff.  182. 


Knife  suitable  for  folding  gold  or  other  foil. 


Fig.  183. 


A  suitable  form  of  tweezers  to  be  employed  in  plugging  teeth. 

of  rubber-dam  protection,  where  both  hands  are  at  liberty,  the 
foil  is  taken  up  by  the  forceps  in  the  left  hand,  wdiilst  by  a  suit- 
able instrument  held  in  the  right  it  is  pressed  down  into  folds 
parallel  with  the  sides  of  the  cavity,  each  fold  being  made  a  little 
longer  than  the  cavity  is  deep,  thus  projecting  slightly  above  its 
oritice.  After  a  few  folds  are  thus  arranged,  the  forceps  are  gently 
removed  and  the  folds  jDressed  against  one  side  of  the  cavity, 
where,  with  a  little  management,  they  will  be  held  with  sufficient 
force  to  support  the  remainder  of  the  tape.  The  instrument  for 
forming  the  folds  in  the  cavity  should  be  flat,  thin,  and  serrated, 
but  not  so  sharp  as  to  cut  the  gold  (Fig.  133);  that  for  com- 
pressing them,  called  from  its  shape  a  foot-plugger  (Fig.  135), 
should  be  slightly  roughened  on  the  surface  which  exerts  the 
pressure,  but  not  so  rough  as  to  adhere  to  the  foil  and  tear  it 
away.^  One  length  of  tape  being  exhausted,  another  is  in  like 
manner  introduced,  and  usually  with  less  difficulty  than  the 
first,  and  the  process  continued  as  before,  care  being  taken  to 
compress  each  thoroughly  with  the  foot-plugger  with  as  much 
force  as  the  walls  of  the  tooth  can  safely  withstand.  Having 
thus  introduced  as  many  lengths  of  tape  as  possible,  a  sharp 
wedge-shaped  instrument  should  be  forced  into  the  centre  of  the 
tilling,  parallel  with  the  folds,  and  moved  backwards  and  for- 
wards, but  with  much  caution,  as  the  leverage  thus  exercised 

'  Mfiny  other  form.s  of  plugger  will  be  found  necessary  ;  those  shown  in  Fig. 
133  are  amongst  the  most  useful. 


TREATMENT    OF    DENTAL    CARIES, 


197 


Oil  the  walls  of  the  cavity  is  considerable.  Into  the  space  thus 
made  more  tape  is  inserted,  and  this  process  continued  until  the 
wedge  is  with  moderate  force  unable  to  penetrate  the  surface. 
The  last  added  portions  not  being  easily  accomplished  by  the 
tape  arrangement,  it  may  be  effected  according  to  the  plan  which 
we  shall  next  detail.  If  the  above  be  carried  into  effect  as 
described,  we  shall  then  have  a  cavity  filled  with  gold  foil,  in 
layers  parallel  with  each  other,  and  held  firmly  by  mutual  com- 
pression, so  that  any  dragging  action  on  the  surface  will  be  re- 
sisted by  the  whole  depth  of  the  foil ;  whereas,  were  the  paral- 
lelism of  the  folds  reversed,  the  layer  at  the  surface  would  be 
sustained  only  by  the  narrow  portion  forming  its  first  fold.  Tiie 
process,  how^ever,  has  yet  to  be  completed,  as  at  this  stage  the 
gold  should  project  slightly  above  the  orifice  of  the  cavity. 

With  instruments  terminating  in  somewhat  broad  extremities, 
and  file-cut,  to  prevent  their  slipping  (Fig.  133),  the  surface  is 
condensed  by  considerable  pressure,  greatly  augmented  by  a 
slight  rolling  movement  being  given  to  them  at  the  same  time. 

Fvr   184. 


Hand  mallet,  the  head  of  which  is  consti-uctcd  of  hard  wood  filled  with  lead,  which  lessens 
the  amount  of  vibration  when  used. 


Fiff.  1S5. 


Automatic  mallet  (Snow  and  Lewis).  The  bit  or  plugger  is  inserted  at  the  small  end  of  the 
instrument,  and  when  pressed  upon  raises  a  mallet  against  the  resistance  of  a  spring,  and  which 
at  a  given  height  is  liberated  by  a  trigger  and  strikes  the  bit.  The  amount  of  force  can  be  regu- 
lated by  the  screw  at  the  head  of  the  instrument. 

[Such  movement  being  very  like  the  carpenter's  u.se  of  the  brad 
awl].  In  the  place  of  hand  pressure,  force  may  be  conveyed  to 
plugging  instruments  by  a  mallet  (Fig.  184),  the  substance  form- 
ing the  head  being  a  soft  metal,  which  occasions  less  vibration 


198        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

Fii?.  186. 


Prof.  Flagg's  condensing  forceps. 

than  does  hard  wood.  The  mallet  may  be  an  automatic  one 
and  then  its  employment  necessitates  only  the  use  of  one  hand. 
The  first  of  such  instruments  was  devised  by  J.  Tomes,  but  the 
American  contrivances  of  Sahnon  and  Snow,  in  which  the  force 
is  regulated  by  a  screw,  are  certainly  preferable. 

[With  these  mallets  the  short  period  of  time,  between  the 
pressure  of  the  point  upon  the  filling  and  the  blow  from  the 
automatic  hammer,  is  with  nervous  people  a  seemingly  much 
prolonged  stage  of  dread,  and  many  will  change  their  dentist 
rather  than  be  forced  to  submit  to  a  repetition  of  this  agony  of 
anticipation. 

The  pneumatic  mallet  of  Williams  gives  most  excellent,  quick, 
and  following  or  squeezing  strokes.  It  is  an  instrument  readily 
kept  in  order,  being  simple  and  neat  in  its  construction.  The 
use  of  the  electric  mallet  has  been  abandoned  of  late  by  many 
who  formerly  advocated  its  employment,  an<l  some  of  the  forms 
of  engine  mallet  have  been  substituted  for  it.] 

When  the  cavity  is  situated  between  teeth— approximal,  as 
it  has  been  termed — the  condensing  pressure  may  be  often 
advantageously  applied  l)y  means  of  compressing  forceps,  one 


TREATMENT  OF  DENTAL  CARIES. 


199 


blade  of  which  is  upttlied  to  the  surface  of  the  filliiio;  and  the 
other  to  the  opposite  side  of  the  tooth.  The  instrument  is 
especially  indicated  for  teeth  somewhat  loose  in  their  sockets, 
as  great  pressure  can  be  em})Ioyed  without  movinij;  them  in  the 
same.  The  degree  of  condensation  will  inform  the  operator  of 
the  extent  of  perfection  to  which  the  first  portion  of  the  process 
has  been  carried;  for  should  lie  be  able  to  condense  to  more 
than  a  slight  extent,  he  may  rest  assured  that  he  has  not 
introduced  the  tapes  as  closely  together  or  wedged  them  as 
tightly  as  thej'  ought  to  have  been.  Such  a  tilling  may  have  a 
hard  surface  and  may  last  for  a  time,  but  not  so  long  as  one  that 
is  more  dense  throughout  in  its  entirety.  If  the  process  be 
successful,  the  surface  after  compression  should  be  still  slightly 
above  the  level  of  the  cavity,  and  it  may  now  be  reduced  witli 
suitably  shaped  tiles  (Fig.  103),  directed  by  the  hand,  or  burs 

Fvr   187. 


File-carrier  for  filling  teeth  at  the  back  of  the  mouth. 

rotated  by  the  engine.  If  at  the  side  of  a  tooth,  endeavor  should 
be  made  to  leave  the  tilling  contour,  /.  e.,  of  the  form  which  that 
portion  of  the  tooth  originally  presented;  but,  if  on  a  masticat- 
ing surface,  experience  shows  that  it  is  best  not  to  attempt  to 
imitate  the  cusps,  a  flat  and  perfectly  level  surface  being  found 
to  stand  the  longest;  indeed,  some  operators  even  reduce  to  the 
same  level  the  adjacent  cusps  of  the  enamel.  After  the  tile  a 
more  perfect  tinish  can  be  given  by  polishing  the  gold  with  an 
Arkansas  point  (Fig.  188),  or  a  little  tinely  powdered  pumice 


Fio-.  IS 


steel  holder  for  carryiuir  Arkansas  or  coruudum  points  for  polishing  stoppings. 

and  water  applied  on  a  piece  of  wood  or  tape  (Fig.  189),  and  as 
a  tinal  ai)itlication,  whiting  or  crocus  in  the  same  manner.  Such 
a  surface  will,  in  a  solid  plug,  be  left  and  remain  highly  polished, 


200 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


with  far  less  tendency  for  food  to  accumulate  about  it  than  if  it 
were  rough  or  uneven.    With  some  operators  it  is  customary  to 


Fiff.  189. 


Fiff.  190. 


Harding's  tape-carrier  with  steel  spring  ratchet  for  tightening  the  tape.     The  instrument  is 
employed  for  polishing  the  surfaces  of  gold  fillings  situated  between  teeth. 

carry  out  much  of  the  finishing  and  polishing  process  by  forcibly 
rubbing  the  gold  surface  with  highly  2:)olished  steel  instruments 
— burnishers  (Fig.  169,  p.  187).  By  their  aid  a  very  highl}- 
polished  surface  may  be  attained,  but  it  is  a  somewhat  deceptive 
one,  especially  where  the  filling  is  none  too  dense,  and  it  seldom 
remains  any  length  of  time. 

2.  By  ropes. — This  is  simply  a  modification  of  the  last  method, 
the  gold  foil  being  rolled  into  a  form  resembling  rope  and  applied 

in  precisely  the  same  manner.  In  this 
.  form  it  is  rather  more  easy  to  manipu- 
late, but  a  less  perfect  parallelism  of  the 
foil  is  attained  ;  it  is  best  suited  to  the 
more  irregularly  shaped  cavities,  into 
the  inequalities  of  which  it  can  be  more 
readily  compressed. 

3.  By  stars  of  strips. — This  process 
consists  in  folding  the  foil  into  a  broad 
tape,  about  half  or  three-quarters  of  an 
inch  in  breadth,  and  then  cutting  it  at 
right  angles  to  its  length  into  narrow 
strips.  Of  these  three  or  four,  arranged 
over  each  other  in  form  of  a  star  (Fig. 
190),  are  taken  up  at  their  centres  by  the 
foil-forceps,  or  the  pointed  extremity  of 
a  plugger,  and  inserted,  the  central  \M)r- 
tions  downwards,  into  the  cavity,  after 
which    the   iiroiecting  ends   are  folded 

Method  of  taking  up  gold  foil  i  i      •  i  i  i 

for  inHcrtion  into  a  cavity  on  the     dowuwards  and    Hiwards,  aiid   pressed 

plan  of  Htars  or  stripH.     The  cut       j,)^^     ^Jj^,     ^  ^.     ^^,^■^     j  ^J^g     forCepS     Or 

to  the  loft  representH  the  mode  of  *  *'_  _    ^      _ 

taking  up  the  foil  with  tweezerHj     pluggcr:    furtlicr  portious   are  in   like 
that  on  the  right  of  doing  ho  on     j^^^,^j,^,g^,  added,  the  foot-pl uggcrs  bcincr 

the  point  of  a  plugger.  '  i       oO  c< 


TREATMENT    OF    DENTAL    CARIES. 


201 


Fi":.  191. 


constantly  eniplo^'cd  to  condense  laterally,  and  the  wedges  used 
in  the  latter  stages,  until  tlie  cavity  is  densely  tilled,  wheu  the 
finishing  process,  as  before,  is  employed.  This 
method  is  best  adai)ted  for  narrow  and  deep 
cavities,  where  a  perfect  parallelism  is  less  im- 
portant, as  the  surface  is  small  in  comparison 
with  the  depth  of  the  cavity:  it  is  also  very 
usefully  combined  with  other  methods,  esjie- 
cially  in  applying  the  last  })ortions  of  gold:  a 
heavy  gold,  twenty  grains  to  the  leaf,  is  in 
such  cases  very  readily  pressed  down  to  the 
bottom  of  a  small  deep  oritice,  when  a  lighter 
foil  would  stick  on  the  way,  or  be  perforated 
by  the  narrow  instrument. 

4.    By  cylinders. — By  this  elegant  method 
the  most  perfect  parallelism  of  folds  is  attained. 


Ficr.  192. 


Tlie  form  iii  which  gold  foil  prepared  in  cylinders  is  now  sold. 


It  is  accomplished  by  dividing,  say,  a  leaf  of 
No.  5  foil  into  two,  three,  or  four  strips,  and 
folding  them  into  tapes,  a  little  broader  than 
the  cavity  to  be  filled  is  deep.    These  are  rolled 


Fis:.  10.S. 


The  form  in  which  gold  foil  prepared  in  blocks  with  parallel 
layers  is  now  sold. 

round  a  fine  broach  or  pair  of  delicate  forceps 
(Fig.  191),  constructed  for  the  purpose,  into 
little  rolls  (Fig.  192),  like  those  in  which  rib- 
bon is  sold.  Cylinders  of  various  thicknesses 
and  sizes,  also  blocks  with  the  foil  [)arallel,  are 
now  prepared  expressly,  and  are  superior  to 
those  made  as  described,  which  are  of  necessity 


Tomes's  foil  roller 
for  making  cylinders 
i  n  foil. 


202    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

thicker  and  more  dense  at  each  end  where  folded  chan  in  the 
centre,  which  is  not  the  case  with  those  sold.  The  cylinders 
are  conveyed  to  the  cavity  in  the  tooth  by  the  foil-forceps,  and 
inserted  with  the  folds  parallel  to  the  walls  of  the  same;  their 
disposition,  when  so  placed,  being  best  understood  by  the  happy 
illustration  of  J.  Tomes,  "packed  into  the  tooth  as  you  would 
proceed  to  pack  cigars  into  a  tumbler." 

Each  cylinder,  as  introduced,  should  be  well  compressed  to 
one  side  of  the  cavity  before  the  next  is  introduced,  and  so  on 
until  no  more  can  be  added ;  but,  as  it  is  difficult  to  complete 
the  operation  with  cylinders,  it  will  be  best  to  accomplish  it  by 
filling  up  the  interstices  made  by  the  wedge  with  foil  in  the 
form  of  strips.  In  treating  interstitial  cavities,  viz.,  those 
existing  between  teeth,  we  shall  find  it  most  convenient  to 
commence  at  the  least  accessible  position,  i.  e.,  where  the  cavity 
impinges  on  the  gum,  and  to  complete  towards  the  crown. 

The  foregoing  descriptions  of  the  methods  of  employing  gold 
foil  are  equally  applicable  to  platina  and  tin.  The  former  is 
not  much  used  on  account  of  its  harshness  and  the  difficulty  ex- 
perienced in  thoroughly  adapting  it,  without  intervening  spaces, 
to  the  irregular  walls  of  some  cavities ;  otherwise,  in  color,  it 
surpasses  gold,  which  also  it  equals  as  regards  freedom  from 
chemical  action. 

Tin,  whilst  sufficiently  pure  and  unalterable  by  reagents,  does 
not  yield  a  plug  sufficiently  hard  to  resist,  in  exposed  situations, 
the  wear  of  mastication  for  many  years:  when  applied  in  situa- 
tions not  so  exposed,  it  appears  to  last  in  some  cases  even  better 
than  gold,  and,  being  an  inferior  conductor  of  heat,  is  well 
suited  to  very  sensitive  teeth,  especially  the  temporary  ones, 
and  also  the  permanent  ones  in  young  persons.  Cavities  situated 
on  the  buccal  surfaces,  and  shallow  cavities,  retain  this  metal 
as  well  as,  and  often  better  than,  any  other  material,  and  it 
might  probably  be  employed  with  advantage  much  more  fre- 
quently than  it  is  at  present. 

[Tin  has  likewise  been  used  to  line  cavities,  from  its  lower 
conductibility,  its  softness,  and  comparatively  easy  adaptation, 
where  gold  was  to  be  the  main  substance  of  the  filling;  lead  in 
like  manner  has  been  used  on  the  Hoors  of  cavities  for  the  last 
quarter  of  a  century  at  least,  and  varnishes,  gutta-[)ercha,  oxy- 
cliloride,oxyphos[)hate,  and  amalgam  have  each  had  their  advo- 


TREATMENT    OF    DENTAL    CARIES.  203 

cates  for  this  purpose.  This  practice,  as  a  universal  rule,  has 
two  objections — one  the  prejudice  felt  against  plated  ware  and 
shams  generally  ;  the  other  the  fact  that  every  compound  filling 
lias  the  additional  jioint  of  weakness  at  the  junction  of  the  two 
materials,  this  being  an  objection  even  to  the  use  of  two  kinds 
of  gold,  as  cohesive  on  non-cohesive.] 

Gold,  however,  possesses  a  special  qualification  under  certain 
conditions,  viz.,  that  of  being  cohesive  either  in  the  precipitated 
form  spoken  of,  or  rendered  so  by  exposure  to  heat:  more  cor- 
rectly, perhaps,  it  should  be  stated  that  gold  is  naturally  cohe- 
sive, but  that  from  exposure  to  air  or  other  gases  it  loses  this 
property,  probably  from  weak  chemical  aflinities  which  attach 
to  its  surface  gases  or  vapors,  and  which  prevent  its  particles 
from  actually  coming  into  perfect  contact  when  two  pieces  of 
the  metal  are  brought  together.  If  a  portion  of  non-adhesive 
gold  foil  be  [lassed  through  the  flame  of  a  spirit-lamp,  at  a  heat 
short  of  redness,  a  va[)or  will  be  seen  to  issue  from  its  surface, 
after  which  such  piece  of  gold  will,  when  pressed  upon  a  similar 
one,  become  united  to  it  so  intimately,  that,  if  an  attempt  be 
made  to  separate  them,  the  gold  will  yield  first  in  many  places 
rather  than  at  the  attached  surfaces.  This  property  is  not 
peculiar  to  gold  or  certain  metals:  it  only  requires  the  actual 
molecules  of  a  body  to  be  brought  sufliciently  close  to  those  of 
another  portion  of  a  similar  body,  or  in  many  cases  a  different 
body,  for  attraction  of  cohesion  to  take  place,  a  condition  most 
readil}'  brought  about  by  the  process  of  liquefaction.^ 

[Probably  very  lew  to-day  understand  that  non-cohesive  gold 
means  a  foil  that  is  not  capable  of  being  made  cohesive  by 
annealing.  Most  cohesive  foils,  if  left  exposed  to  the  air,  lose 
that  property  tem[)orarily,  and  are  capable  of  being  used  some- 
what like  non-cohesive  gold,  with  the  great  objection  that  they 
are  more  harsh  or  stiff,  and  liable  to  break  or  fold  in  sharp 
angles.  The  non-cohesive,  such  as  has  been  made  by  Messrs. 
Chas.  Abbey  &  Son  for  the  last  sixty-five  years,  has  the  kid-like 
softness  which  makes  it  perfectly  passive  under  the  instrument, 
lying  just  where  it  is  })ut.     The  force  necessary  to  work  it  is 

'  Whilst  making  the  foregoing  statement,  with  regard  to  gold  being  rendered 
cohesive,  we  must  admit  that  a  certain  eminent  English  chemist  regards  the 
union  as  simply  a  mechanical  adhesion. 


204    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOaY. 

about  that  which  is  required  to  work  lead,  and  gold  has  the 
advantage  of  toughness  which  allows  it  to  be  pushed  before  the 
instrument's  point  without  being  penetrated  by  it.] 

Gold  possessed  of  the  property  of  cohesion  can,  it  will  be 
clearly  perceived,  he  employed  with  much  advantage  in  a  variety 
of  cases,  especially  in  filling  shallow  cavities,  building  up  lost 
portions  of  the  teeth,  etc. 

In  considering  the  subject  of  filling  teeth  with  cohesive  gold' 
it  will  be  advisable,  first,  to  give  some  attention  to  the  shaping 
of  cavities  with  relation  to  their  means  of  retaining  the  filling. 

The  primary  point  to  determine  is,  whether  the  filling  shall 
be  held  in  entirely  by  the  general  form  of  the  cavity,  or  by  re- 
taining points  or  pits;  the  former  being  the  more  to  be  desired 
and  the  most  generally  applicable ;  the  latter,  however,  must  be 
relied  on  in  certain  shallow  cavities,  when  the  filling  must  be 
entirely  cohesive. 

Let  us  take  as  an  example  a  saucer-shaped  cavity  on  an 
approximal  surface  of  a  cuspidatus  tooth,  where  we  will  suppose 
the  decay  to  have  penetrated  but  little  further  than  the  enamel. 
On  all  the  disorganized  enamel  being  chipped  awa}^,  together 
with  any  diseased  dentine  that  there  may  be,  and  the  edges  of 
the  enamel  being  smoothed  otii"  with  an  Arkansas  wheel  on  the 
dental  engine,  a  shallow  saucer-shaped  cavity  will  be  left,  per- 
fectly incapable  of  retaining  any  filling  that  will  not  adhere  to 
its  walls. 

If  into  such  cavity  half  a  dozen  retaining  pits  be  now  drilled 
near  to  the  margin  of  the  dentine,  in  directions  divergent  from 
one  another,  and  so  as  to  avoid  all  proximity  to  the  pulp-cham- 
ber, sufficient  hold  will  be  attained  to  securely  retain  the  gold. 

[The  number  of  pits  may  vary  from  three  to  six,  according 
to  the  strengtii  of  the  walls;  if  these  are  weak  the  pits  must  be 
shallow,  but  gaining  by  number  for  lack  of  individual  strength. 
The  principle  of  putting  in  retaining  pits,  may  be  likened  to  a 
three-legged  stool,  in  which  the  direction  of  the  legs  is  in  a  line 
with  the  forces  to  be  resisted,  and  so  inclined  that  they  would 
meet  if  brought  to  a  common  point  of  resistance.  If  the  force 
the  filling  has  to  withstand  is  greater  toward  one  point  than 

'  In  the  following  description  we  liavo  availed  ourselves  of  the  kind  assistance 
of  Claude  S.  Rogers,  the  demonstrator  at  tlie  scliool  of  tiie  Dental  Hospital  of 
London. 


TREATMENT    OF    DENTAL    CARIES, 


205 


another,  that  one  may  be  strengtliened  by  extra  size  of  the  pit, 
or  if  the  wall  be  weak  by  an  extra  number.] 

For  making  these  retaining  pits,  a  small  square-pointed  drill 
(Fig.  194)  should  be  used,  and  the  pits  cut  no  deeper  into  the 


Fisr.  194. 


Fi''.  195. 


Spade  drills.  A  sliallow  and  spoon-shaped  cavity  in  a  cuspi- 

datus  tooth  with  two  retaining  points  at  its  gin- 
gival margin  and  two  retaining  grooves,  one  at 
each  side,  cut  into  it. 

dentine  than  about  the  diameter  of  the  drill  itself;  or  a  small 
wheel-bur  (Figs.  Ill  and  118)  used  in  the  engine  will  do  equally 
well.  If  the  cavity  be  somewhat  deeper  than  has  been  supposed 
in  the  foregoing,  it  may  be  well  to  join  two  or  three  of  these 
pits  together  on  two  opposite  sides  of  the  cavity,  thus  forming 
two  opposing  grooves  (Fig.  195). 

In  these,  as  in  all  other  forms  of  cavity,  the  enamel  edges 
should  be  smoothed  off  either  with  au  Arkansas  wheel,  as  before 
mentioned,  or  wnth  small  chisels  ;  in  fact,  a  somewhat  counter- 
sunk form  should  be  given  to  the  edges,  so  that  the  plug  when 
completed  shall  fit  like  a  screw-head  (see  Fig.  145,  p.  168). 

The  cavity  having  been  prepared  and  the  rubber-dam  applied, 
if  that  has  not  been  previously  done,  the  cavity  is  now  ready 
for  the  filling. 

The  gold  should  be  emplo3'ed  in  loosely  rolled  pellets;  small 
sizes  of  Williams's  A  cylinders  answer  exceedingly  well.  [For 
cohesive  gold  the  sheet  of  No.  4  Abbey's  may  be  folded  twice 
by  turning  the  outer  edge  of  the  leaf  as  it  lies  in  the  book  in 
toward  the  sewed  part  or  back  of  the  book ;  then  closing  the 
book  and  pressing  lightly  with  the  fingers  to  flatten  the  sheet. 
Repeat  this  folding  and  we  will  have  a  ribbon  one-fourth  the 
Avidth  of  the  original  sheet,  which  may  be  cut  off  into  eight  or 
more  pieces,  according  to  the  size  of  tlie  cavity  in  the  tooth.] 


206 


MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY, 


If  foil  be  preferred,  J!^o,  4  is  the  best,  whole  sheets  being  made 
into  a  rope  and  cut  up  into  small  pellets.  As  this  should  be 
done  before  the  foil  is  annealed,  it  is  best  to  use  non-cohesive 
foil,  to  be  made  cohesive  by  heating  slightly  in  a  tray  over  the 
spirit-lamp  (Fig.  196),  or  b}^  passing  each  pellet  over  the  flame 


Fi?.  196. 


Fig.  197. 


Spirit-lamp  and  tray  for  h<>ating 
(annealing)  gold  foil. 


Spirit-lamp  suitable  for  heating 
(annealing)  gold  foil. 


before  placing  it  in  situ.  In  annealing  the  gold,  care  should  be 
taken  not  to  over-heat  it,  as  in  that  case  the  gold  becomes  harsh 
and  brittle,  losing  all  the  beautiful  softness  that  it  possesses:  if 
this  be  avoided,  a  degree  of  heat  considerably  below  redness  is 
all  that  is  necessary ;  indeed,  for  very  small  pellets  a  single  wave 
over  the  spirit-flame  will  be  found  sufiicient. 

The  gold  having  been  thus  prepared,  we  proceed  to  fill  each 
retaining  pit  with  the  pellets,  conveying  them  by  means  of  the 
foil-carriers  and  thoroughly  condensing  each  pellet  as  it  is  put 
in  its  place.  This  is  best  done  with  pluggers  having  fine  serrated 
points  (Fig.  199),  which  may  receive  their  force  from  the  hand, 
from  the  ordinary  mallet  (Fig.  184,  p.  197),  from  the  automatic 
mallet  (Fig.  185,  p.  197),  from  the  pneumatic  mallet  (Fig.  200), 
which  is  worked  by  the  foot,  from  a  very  ingenious  mallet  which 
can  be  attached  to  the  dental  engine  (Fig.  201),  or  from  the 
electro-magnetic  mallet  (Fig.  203).  [A  following  or  dead  blow, 
as  from  the  pneumatic  or  the  lead  mallet,  is  desirable;  the 
efi'ort  being  to  imitate  the  squeeze  of  a  vice  as  much  as  possible, 
80  that  the  gold  is  laid  in  its  place  gently  but  firmly  and  held 


TREATMENT    OF    DENTAL    CARIES. 


207 


there  by  a  momentary  persistence  of  the  pressure.]    The  retain- 
ing pits  being  filled,  the  gold  is  carried  over  from  one  to  the 


Fiff.  198. 


Rich's  tweezers  suitable  for  carrying  cohesive  foil  to  the  retaining  points  or  grooves. 
Fig.  199. 


/' 


Three  forms  of  plugger  suitable  for  condensing 
cohesive  foil. 


FlV.  200. 


F\<r.  201. 


Power's  mallet,  which  is 
attached  to  and  worked  by 
the  dental  engine. 


Kirby's  pneumatic  luallet. 


208 


MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY, 


Fig.  203. 


Three  forms  of  bit  to  be  employed 
with  Power's  engine  mallet. 


other,  across  and  back  again,  gradual] \'  covering  the  surface  of 
the  cavity,  tlie  centre  first  and  the  margins  afterwards.  This 
should  not  be  done  too  quickly,  as  there  is  a  tendency  in  the 

gold  to  curl  away  from  the  surface 
if  the  mass  be  too  thin:  a  careful 
guard  should  therefore  be  kept,  that 
the  plug  in  its  earl}'  stages  is  suffi- 
ciently strong  in  its  centre  to  prevent 
this.  We  now  proceed  to  mass  on 
the  pellets,  using  larger  ones  as  the 
plug  becomes  stronger,  until  the  gold 
stands  fairly  above  and  over  all  the 
edges  of  the  cavity,  when  it  is  filed 
or  cut  down  with  corundum  wheels 
in  the  engine  (Fig.  204)  to  the  con- 
tour of  the  face  of  the  tooth,  and 
smoothed  off  with  Arkansas  stone, 
so  that  a  pointed  instrument  can  be  passed  from  the  gold  to  the 
enamel,  and  vice  versa,  without  there  being  any  catch  perceptible 
to  the  touch.  The  finishing  process  is  polishing  with  crocus 
pjowder  on  a  soft  rubber  point. 

If  sponge  g(dd  be  emplo^^ed,  the  process  is  conducted  in  the 
same  manner,  somewhat  smaller  pieces  being  used.  The  con- 
densing force  also  requires  to  be,  if  anything,  rather  more  care- 
fully and  thoroughly  done,  commencing  a  partial  condensation 
with  a  large  plugger,  then  employing  a  smaller  one,  and  then  a 
still  smaller  one;  and  thus  each  piece  is  treated  as  it  is  placed 
in  situ. 

When  sponge  gold  first  attained  its  great  j)opularity,  it  was 
estimated  that  with  it  operations  could  be  done  with  greater 
ra[)idity  than  with  the  foil.  Time,  however,  showed  that  the 
apparently  sound  and  beautiful  fillings  thus  effected  were  not 
solid  ;  in  fact,  only  the  outer  fibres  of  each  piece  were  condensed, 
the  centres  remaining  porous,  so  that  fluids  of  the  mouth  soon 
worked  into  the  weak  portions,  and  decay  went  on  around  the 
filling.  If,  however,  small  pieces  be  used,  as  before  stated,  and 
each  piece  thoroughly  condensed  with  small  points,  as  good  a 
filling  can  be  made  of  sponge  gold  as  with  foil  ;  it  requires, 
however,  more  time  and  labor,  and  it  is  in  this  respect  that  the 


TREATMENT    OF    DENTAL    CARIES, 


209 


chief  objection  to  it  lies.     In  employing  any  form  of  adhesive 
gold  it  is  all-important  that  it  be  kept  perfectly  dry  during  the 


Fiff.  203. 


Electro-macrnetic  mallet. 


process;  should  moisture  happen  to  get  to  it,  the  surface  must 
be  again  rendered  quite  dry  by  wiping  it  with  amadou,  after 


Fia;.  204. 


Corundum  wheel  attached  to  the  mandrel  of  a  dental  engine,  which  is  capable  of  being  fixed  at 

various  angles.' 

washing  it  with  pure  water  or  spirit,  and  finally  by  blasts  of 
heated  air  from  the  air-syringe  (Fig.  206). 

14 


210    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

[It  will  generally  be  found  more  expeditious  and  satisfactory 
to  remove  at  once  all  the  gold  and  renew  the  operation.  In 
attempts  to  work  over  a  surface,  the  cohesive  property  of  which 
has  been  destroyed  by  moisture,  precious  time  is  lost,  the  result- 
ing fatigue  disheartening  alike  the  operator  and  the  patient.] 

Fia:.  205. 


Corundum  wheel  mounted  with  Ives'  tongue  and  cheek  protector. 

The  combination  of  soft  with  cohesive  gold  is,  however,  by 
far  the  preferable  method,  as  the  former  can  be  more  readily 
placed  and  driven  into  deep  undercuts:  it  is  also  far  better 
adapted  to  the  cervical  walls  in  approximal  cavities.     Since 


Hot-air  syringe  (Moffat's).     In  using  it  the  metal  air-chamber  is  heated  in  the  flame  of  a  spirit- 
lamp,  and  the  air  propelled  through  it  becomes  heated  and  dried. 

annealed  gold  will  cohere  readily  to  the  unannealed  form,  or 
retaining  pits  in  the  latter  are  readily  obtained,  a  good  starting 
})oint  for  the  cohesive  pellets  can  be  thus  made.  A  description 
of  one  or  two  of  the  more  difficult  cases  may  serve  as  good  ex- 
amples of  this  process  of  iilling  cavities  with  gold. 

[An  attempt  should  always  be  made  to  work  after  some  defi- 
nite plan.  Just  as  an  engineer  lays  a  foundation,  raises  walls, 
builds  buttresses  and  arches,  so  after  a  cavity  has  been  freed 
of  all  diseased  and  softened  dentine,  and  the  over-hanging  walls 
of  enamel  cut  down,  a  plan  for  its  filling  shonld  be  decided 
upon,  and  proper  excavatioiis  for  foundations  made.] 

We  will  take  a  carious  cavity  of  decay  extending  over  the 
whole  mesial  wall  of  an  ui»[)or  incisor  tooth,  encroaching  upon 


TREATMENT    OF    DENTAL    CARIES.  211 

its  labial  and  lingual  surfaces,  and  up  to  but  not  beneath  the 
gum.  We  first  cut  away  all  frail  edges  of  enamel  with  fine 
chisels,  which  pertnits  the  cavity  to  be  freely  viewed  in  all  parts 
for  the  removal  of  the  decay  and  for  filling,  and  at  the  same 
time  renders  the  labial  and  lingual  walls  less  liable  to  fracture. 
We  next  remove  the  decayed  dentine,  carefully  avoiding  the 
neighborhood  of  the  pulp,  and  for  this  purpose  tlie  spoon- 
shaped  excavators  will  be  found  of  excellent  service  (see  Fig. 
106,  p.  142). 

All  decay  having  been  carefully  removed,  the  next  step  is 
to  shape  the  cavity  so  that  it  will  retain  the  tilling  securely. 
Sometimes  there  is  sufiBcient  left  of  the  labial  and  linijual  Avails 
to  admit  of  a  slight  groove  being  made  all  round,  except  at  the 
cervical  wall  of  the  cavity,  that  being  kept  as  flat  as  possible, 
for  fear  of  leaving  the  thin  enamel  there  to  be  split  ofl:"  with 
pressure,  to  which  it  is  very  liable.  More  often,  however,  it 
will  be  necessary  to  partly  or  wholly  remove  these  walls,  leaving 
a  somewhat  spoon-shaped  cavity :  in  such  a  case  anchorage  is 
obtained  for  the  filling  by  cutting  two  opposite  angles,  one  of 
which  may  be  termed  the  cervico-labial,  and  the  other  the  cer- 
vico-lingual,  angle,  and  a  third  good  retaining  angle  or  pit  may 
be  made  between  these  towards  the  cusp  of  the  tooth.  If  these 
three  angles  be  cut  sufiiciently  deep,  though  not  so  deep  as  to 
materially  weaken  the  strength  of  the  tooth-substance  at  such 
points,  a  perfectly  secure  hold  for  the  tilling  will  be  obtained. 
To  proceed  with  the  filling:  we  take  a  soft  cylinder  of  medium 
density,  and  place  it,  transverse  to  the  long  axis  of  the  tooth, 
at  the  cervico-lingual  angle,  and  with  a  fine  foot-plugger  press 
it  against  the  lingual  wall.  If  it  will  not  lodge  there  alone,  we 
hold  it  in  its  place  with  another  instrument  held  in  the  other 
hand,  and  insert  a  second  cylinder,  or  a  third,  and  a  fourth  if 
necessary,  until  the  cervico-labial  angle  is  reached,  when,  tak- 
ing a  large  foot-[)lugger,  we  press  the  whole  mass  towards  the 
cervical  wall.  If  tlie  angles  have  been  sutficiently  and  properly 
cut,  they  will  be  all-sufficient  to  hold  firmly  in  place  this  bed  of 
soft  gold:  if  not,  it  must  be  firmly  pressed  there  with  an  in- 
strument in  the  left  hand,  until  sufiicient  of  the  non-cohesive 
gold  has  been  built  on  to  allow  of  its  being  removed  without 
any  fear  of  the  mass  shifting  its  position.  On  this  bed  of  soft 
gold  cohesive  pellets  can  be  packed,  each  one  being  condensed 


212        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

with  tlie  mallet  well  up  to,  but  not  on  to,  the  walls  of  the  cavity, 
care  being  taken  to  see  that  the  lingual  edge  is  well  perfected 
during  the  process,  since  this  part  is  the  most  difficult  to  rec- 
tifj'-  afterwards;  if  it  be  not  so,  we  keep  the  gold  well  out  in 
the  required  contour,  so  as  to  do  as  much  of  the  malleting  in 
the  long  axis  of  the  tooth  as  possible,  as  in  this  direction  it  will 
tolerate  force  better  than  in  any  other.  If  the  angle  at  the 
junction  of  the  lingual  and  labial  walls,  i.  e.,  near  the  cusp  of 
the  tooth,  be  a  deep  one,  then  one  or  two  small  soft  non-cohesive 
cylinders  may  be  placed  there  on  which  the  cohesive  foil  is  to 
be  built,  and  at  this  point  it  will  be  necessary  to  change  the 
direction  of  the  force  to  the  transverse.  The  remainder  of  the 
operation  is  the  piling  on  of  cohesive  pellets  up  to  the  contour 
of  the  tooth,  letting  it  come  well  up  to  and  over  its  edges:  we 
then  trim  down  with  various  forms  of  corundum  wheels  and 
files  applicable,  and  polish  with  tape  and  polish  powders. 

For  our  second  example  we  will  take  the  case  of  approximal 
decay  on  the  anterior  surface  of  an  upper  second  bicuspid,  ex- 
tending from  the  crown  to  the  gingival  margin,  the  pulp  not 
being  invaded.  In  all  these  cases,  whether  the  decay  extends 
quite  to  the  grinding  surface  or  only  nearly  to  it,  it  is  best  to 
cut  right  down  from  the  crown  with  the  enamel  chisel,  clearing 
away  the  undercut  angles  beneath  the  cusps,  since  by  this 
means  a  much  more  effectual  stopping  can  be  made,  as  we  get 
rid  of  corners  where  it  is  most  likely  to  fail  from  imperfect 
packing;  also  the  whole  of  the  cavity  is  well  open  to  view. 

We  next  remove  all  frail  portions  of  the  enamel  as  before,  and 
shape  the  cavity  either  by  so  sloping  the  walls  that  the  filling 
shall  be  retained  like  a  carpenter's  dovetail,  or  by  making  two 
lateral  grooves  which  shall  diverge  as  they  proceed  upwards.  If 
it  be  decided  to  proceed  on  the  former  plan,  small  obtuse-angle 
chisels  should  be  used,  so  cutting  the  lingual  and  labial  walls 
that  they  shall  converge  in  the  direction  of  the  neighboring 
tooth  and  diverge  in  the  upward  direction,  leaving  the  cervical 
wall  quite  flat,  the  enamel  edge  being  slightly  bevelled  off.  [For 
this  purpose  the  fissure  bur  (No.  55|  to  59,  Fig.  208)  and  small 
oval  bur  (No.  88|  to  93,  Fig.  209)  are  useful,  being  moved  up  and 
down  where  the  groove  is  to  be  made.  Care  must  be  taken  that 
the  bur  be  not  large  enough  to  weaken  the  wall  outside  the 
groove  or  to  expose  the  pulp.]     The  cutting  shouhl  be  carried 


TREATMENT    OF    DENTAL    CARIES. 


213 


far  enough  upwards  to  form  cervico-lingual  and  cervico-labial 
angles,  that  rounded  form  of  cervical  wall  being  thus  removed 
which  is  so  frequently  a  cause  of  rocking  of  the  filling  when 
partially  completed. 


Fiff.  207. 


[Fig.  208. 


[Fig.  209. 


Fissure  burs.] 


Oval  buis.] 


A  cavity  in  a  bicuspid  tooth 
prepared  for  filling  by  the 
combined  process,  i.  e.,  with 
soft  and  cohesive  gold  foil. 


Should  any  fissure  of  decay,  however  slight,  exhibit  itself  on 
the  grinding  surface,  it  must  be  cut  out,  as  this  will  also  add 
materially  to  the  retention  of  the  filling. 

In  inserting  the  gold  much  the  same  process  is  pursued  as 
in  the  last-mentioned  case ;  large,  soft,  non-cohesive  cylinders 
are  placed  at  the  cervical  wall,  with  their  cut  ends  projecting 
towards  the  neighboring  tooth,  commencing  at  one  angle  and 
progressing  to  the  other,  when  they  are  condensed  towards  the 
cervical  wall:  if  the  angles  and  walls  have  the  proper  form,  this 
mass  of  gold  will  be  held  firmly  in  its  place.  Another  row  of 
soft  cylinders  may  be  placed  on  this  if  it  be  a  deep  cavity,  and 
then  condensed  upwards  in  the  same  manner,  about  one-half 
the  cavity  being  thus  filled  with  non-cohesive  gold. 

On  this  cohesive  pellets  are  packed  in  the  usual  manner,  care 
being  taken  always  to  carry  the  condensing  force  well  up  to  the 
tooth  substance.  If  a  crown  fissure  exist,  this  should  be  also 
tilled  with  cohesive  gold,  and  united  to  that  in  the  main  cavity: 
we  then  file  down  and  finish  in  the  usual  way. 

Tin  cylinders  may  be  used  instead  of  gold  at  the  cervical 
wall,  and  especially  in  those  cases  where  the  decay  extends 
below  the  gum  ;'  tin  having  the  advantage  of  remaining  per- 


'  We  desire  to  make  this  statement  with  some  reservation,  as  we  have  seen 
cases  in  which  there  has  been  an  appearance  of  the  filling,  so  performed,  hav- 


214    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

fectly  soft  and  adaptable  after  any  amount  of  condensation,  it 
can  be  better  condensed  and  burnished  on  to  the  edge  of  a  cer- 
vical wall  than  gold.  It  is  sometimes  well  to  partially  finish 
the  surface  of  the  filling  at  the  cervical  wall  when  the  filling  is 
only  half  completed,  as  then  it  is  more  easily  reached  than  when 
the  whole  plug  has  been  finished  and  built  out  against  the 
neighboring  tooth. 

This  plan  is  more  especially  advantageous  when  two  con- 
tiguous fillings  of  this  description  are  efiected  at  one  sitting  ; 
that  is  to  say,  we  file  or  cut  down  with  a  chisel  the  superfluous 
tilling  from  the  upper  half  of  both  of  them  to  the  required  level, 
leaving,  however,  the  polishing  of  these  parts  until  afterwards, 
and  finishing  as  before. 

[Dr.  Jack's  matrices,  when  properly  adjusted,  make  the  finish- 
ing of  approxiraal  surfaces  comparatively  an  easy 

Fig.  210.  matter,  and  enable  the  operator  to  gain  a  den- 

sity and  adaptation  of  the  gold  to  the  tooth,  that 
are  invaluable.] 

In  cases  where  the  decay  is  small,  and  situated 
Jack's  matrices.      too  high  up  on  the  proximal  surface  of  a  tooth 
to  justify  the  cutting  down  from  the  crown,  an 
opening  may  be  made  by  cutting   in  from  the  labial  or  buccal 
wall,  and  shaping  the  cavity  as  before  directed, — merely  trans- 
posing its  relative  positions. 

In  attempting  to  draw  any  comparison  between  the  two 
kinds  of  gold  filling,  it  may  be  stated,  that,  whilst  the  cohesive 
is  probably  the  more  dense  and  solid,  and  less  liable  to  wear  or 
chip  away,  it  is  certainly  less  elastic,  and  more  likely,  as  in  the 
case  of  amalgams,  to  become,  by  changes  of  temi)erature,  slightly 
detached  Irom  the  walls  of  a  cavity.  The  slight  elasticity  which 
a  non-cohesive  filling  possesses  com[)ensates  for  any  change  of 
temperature. 

ing  failed  from  electro-cbemical  action  at  the  point  where  the  two  metals  came 
in  contact. 

[It  seems  unlikely  that  the  joining  of  the  two  metals  would  make  a  very 
serious  difiFerence,  indeed,  when  the  sensation  of  galvanic  action  in  the  tooth  is 
persistent,  it  is  recommended  to  relieve  it  by  joining  the  metals  by  an  increase 
in  the  size  or  an  intermediate  filling. 

When  an  ordinary  amalgam  filling  is  not  kept  bright  and  polished,  its  surface 
soon  becomes  covered  with  oxide  and  grease  sufl^lciont  to  reduce  the  galvanic 
action  to  an  almost  imperceptible  amount,  if  not  altogether.] 


TREATMENT    OF    DENTAL    CARIES.  215 

"We  may  venture,  however,  to  lay  down  the  rule,  that,  whilst 
the  non-cohesive  method  is  the  best  for  small  and  fairly  deep 
cavities,  the  cohesive  method  is  decidedly  the  best  for  very 
large  and  shallow  ones.  The  majority  of  very  large  cavities 
filled  with  non-cohesive  gold  are  seen  to  fail  after  a  few  years. 

[The  condensation  of  thin  plates  of  cohesive  gold  against  the 
walls  not  infrequently  causes  crumbling  of  them  or  sufficient 
destruction  of  their  integrity  to  make  the  filling  a  disappoint- 
ment, both  for  the  operator  who  respects  his  reputation  and  for 
the  patient  who  has  placed  his  faith  in  the  salvation  of  the  tooth 
by  the  filling.] 

Gold,  it  must  be  admitted,  when  solid  and  highly  polished, 
is  in  the  front  of  the  mouth  very  conspicuous.  To  obviate  this, 
the  following  ingenious  method  has  been  adopted  by  some. 
Thin  leaves  of  platina  are  gilded,  and  made  adhesive,  and  then 
are  worked  in  parallel  layers,  and,  when  filed  and  polished,  the 
color  of  the  combined  metals  resembles,  to  a  very  considerable 
degree,  that  of  the  teeth.  The  process  must  be  conducted  with 
considerable  care;  first  in  the  aimealing  of  the  foil,  as,  if  not 
heated  sufficiently,  it  will  not  be  adhesive,  and,  if  a  little  over- 
heated, the  gold  readily  melts  off  from  the  platina.  A  perfect 
parallelism  of  the  layers  must  also  be  maintained,  otherwise 
there  will  appear  on  the  surface  patches  of  gold.  [Combination, 
for  the  sake  of  color,  of  perpendicular  layers  of  tin  and  gold  have 
in  like  manner  been  used.] 


216    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


CHAPTER    IX. 

TREATMENT  OF  DENTAL  CAB.IES.— Continued. 

"We  must  now  describe  some  of  the  difficulties  and  complica- 
tions not  uufrequentlj  met  witli  iu  the  operation  of  filling 
teeth. 

First,  with  regard  to  the  position  of  the  cavity;  it  may  be 
so  placed  that  no  justifiable  employment  of  the  chisel  or  file  can 
obtain  room  for  the  insertion  of  the  stopping,  or,  indeed,  for  the 
proper  excavation  of  the  cavity.  To  etiect  our  object,  then,  the 
teeth  must  be  separated,  and  this  separation  may  be  either  im- 
mediate or  mediate.  The  immediate  method  consists  in  taking 
a  thinl^'-pointed  wedge  of  wood,  inserting  its  point  between  the 
teeth  where  lies  the  cavity,  near  to  or  even  a  little  below  the 
gum,  and  then  giving  to  the  wedge  a  smart  blow  or  blows  with 
a  mallet  until  sufficient  space  is  attained;  a  portion  of  each 
projecting  end  is  then  cut  oft'  with  cutting  pliers.  The  sensa- 
tion to  the  patient  is  by  no  means  agreeable,  and  the  operation,  if 
performed  without  due  caution,  may  endanger  the  vitality  of 
the  teeth,  or  even  liberate  one  of  them  from  its  alveolus,  to  the 
vexation  of  patient  and  operator.  We  do  not  recommend  the 
plan  as  so  pursued,  but  we  may  often,  especially  where  no  very 
great  or  increased  amount  of  room  is  required,  ol)tain  it  by  sim- 
ply pressing  steadily  with  the  lingers  a  similar  wedge  of  wood 
cut  from  a  piece  of  soft  deal,  which  has  been  firmly  compressed 
in  a  strong  vice  for  some  hours:  such  a  wedge  will  expand 
when  moistened,  but  the  force  is  gradual  and  even,  not  sudden 
and  violent. 

[Dr.  Corydon  Palmer  has  described  a  method  of  rapid  wedg- 
ing which  is  not  open  to  all  the  objections  of  this  plan.  A 
wedge  cut  from  a  thin  tape  of  wood  or  quill  is  first  placed  be- 
tween the  teeth  to  protect  the  gum.  Next  to  that  a  square- 
tapered  wedge  of  orange  or  box  wood  is  put  at  the  gum,  so  as 
not  to  interfere  with  the  view  of  the  wall  of  the  cavity.     This 


TREATMENT    OF    DENTAL    CARIES.  217 

is  to  remain  during  the  operation,  and  is  driven  to  hold  the  space 
gained  by  the  third, — a  broad  wedge  wliich  is  pressed  by  hand 
or  mallet  between  the  cutting  edges  of  the  teeth  with  its  point 
toward  the  gum.     The  operation  is  performed  little  by  little, 

Fig.  211. 


Dr.  Jarvis's  screw  separators. 

allowing  some  intermissions  between  the  different  steps  for  the 
tissues  to  accommodate  themselves  to  the  increasing  pressure. 
Sometimes  the  screw  separators  of  Dr.  Jarvis's  pattern  are  sub- 
stituted for  this  third  wedge,  and  it  has  been  recommended 
that  the  teeth  may  be  protected  by  thin  slips  of  wood,  but  a 
little  care  in  their  use  is  generally  sufficient.  Rapid  wedging 
should  be  limited  to  cases  where  the  space  desired  is  not  very 
great,  and  the  structures  supporting  the  teeth  are  comparatively 
soft  and  spongy.] 

If  the  room  so  afforded  be  not  sufficient,  the  wedge  may  be 
cut  close  to  the  teeth  and  gum,  and  left  in  situ  for  a  day  or  two, 
then  changed  for  a  larger  one,  and  so  on,  till  sufficient  space  is 
attained,  which  space  is  soon  lost  after  discontinuance  of  the 
wedge.  Where  the  rubber-dam  is  not  employed,  the  wedge, 
from  its  position,  serves  the  useful  purpose  of  preventing  moist- 
ure from  the  gum  having  access  to  the  cavity,  and,  by  forming 
an  artificial  ledge,  often  assists  in  retaining  the  gold  first  in- 
serted at  the  cervical  edge  of  the  cavity.  Instead  of  the  wedge, 
strips  of  India-rubber  may  be  employed,  but  in  our  ex[)erience 
these  cause  more  irritation  and  discomfort  than  the  wood. 
Cotton  pressed  between  the  teeth  and  changed  daily  will  in  a 
little  time  effect  a  considerable  separation  in  the  teeth,  and 
gutta-jiercha  likewise  will  so  act  upon  them  when  packed 
closely  between  the  two  teeth.  The  last  mentioned  is  a  conve- 
nient plan  when  a  second  visit  is  not  obtainable  for  some  three 
to  six  months. 

[It  is,  however,  dangerous  to  leave  teeth  with  a  wedge  be- 
tween them  for  so  long  a  time,  since  the  irritated  gum  seems  to 


218   MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

secrete  a  mucus  highly  injurious  to  the  teeth,  and  cavities  may 
thus  be  seriously  enlarged.  Generally  the  rubber  may  be  left 
one  day,  and  after  that  a  piece  of  cotton-wool  saturated  with 
sandarach  varnish,  or  dry  cylinders  of  letter  paper,  may  be 
packed  in  to  maintain  the  space  for  another  day  and  relieve  the 
soreness.  In  this  way  the  teeth  will  be  generally  well  enough 
to  fill  on  the  third  day.  Dry  cotton-wool  or  several  thicknesses 
of  tape,  gradually  increasing  the  number,  may  be  used  for  gain- 
ing the  space  required  with  comparative  ease  to  the  patient. 
Provided  the  occlusion  of  the  teeth  does  not  add  to  their  sore- 
ness by  bringing  the  cusps  against  each  other,  instead  of  the 
normal  occlusion — cusps  into  depressions — slow  wedging  is  gene- 
rally preferable.] 

A  cavity  in  a  tooth  thus  situated  may  be  excavated  as  far  as 
possible,  and  gutta-percha  introduced  and  left  projecting  against 
the  adjoining  tooth.  "We  have  never  seen  injury  arise  from  the 
gutta-percha  in  contact  with  the  sound  tooth,  but  if  cotton  be 
used,  it  should  be  moistened  with  alcohol  or  Eau  de  Cologne 
before  being  applied. 

From  the  manner  in  which  we  have  spoken  of  the  operation 
of  excision,  and  the  excavation  of  cavities  in  carious  teeth  for 
receiving  fillings,  it  might  almost  be  imagined  that  we  had  to 
deal  with  structures  as  free  from  sensation  as  hair,  nails,  etc. 
Unfortunately  it  is  mostly  otherwise ;  dentine  is  often  acutely 
sensitive,  and  its  excision  so  unbearable  that  no  other  than  a 
very  enduring  patient  can  tolerate  the  process ;  and  this  perhaps 
constitutes  one  of  the  greatest,  if  not  the  greatest,  difficulty 
which  the  dental  surgeon  has  to  encounter  in  his  conservative 
efforts.  The  cause  of  this  sesthesia,  though  perhaps  not  a  finally 
settled  point,  is  generally  admitted  to  depend  upon  the  contents 
of  those  minute  canals, — the  dentinal  tubuli, — which  ramify 
from  the  pulp  chamber  to,  and  often  beyond,  the  peripheral 
surface  of  the  dentine.  At  first  regarded  as  solid  fibres,  then 
as  tubes  conveying  nutritive  fluid,  they  were  shown  by  J.  Tomes 
to  be  tubes,  containing  soft  semi-solid  contents,  and,  like  nerve- 
filaments,  capable  of  conducting  sensory  impressions.  Later 
research  has  shown  them  to  be  prolongations  of  those  cell-like 
bodies,  the  odontoblasts,  which  are  arranged  in  a  layer  on  the 
outer  surface  of  the  pulp,  and  appear  so  intimately  concerned 
in  the   formation   of  dentine.     Tlieir    union   with    the  nerves 


TREATMENT    OF    DENTAL    CARIES.  219 

which  ramify  throucrhout  the  pulp  has  not  yet  been  clearly 
established;  they  may,  as  Boll'  conjectures,  but  has  not  been 
able  to  verify,  be  so  united  within  the  dentinal  tubuli ;  and 
this,  we  believe,  we  have  made  out  in  the  pulp  of  a  calf;  or  it 
may  be  through  the  stellate  cells  of  the  pulp  itself. 

"With  respect  to  the  odontoblasts,  we  are  inclined  to  accord 
to  them  another  function  besides  the  important  one  of  assisting 
in  the  development  of  dentine,  viz.,  a  special  sensory  property 
like  that  of  touch-corpuscles,  Pacinian  bodies,  rods  and  cones 
of  the  retina,  the  olfactory  cells,  and  various  similar  bodies  in 
the  auditory  apparatus,  all  connected  with  nerves,  and  which 
in  the  teeth  renders  them  capable  of  judging,  and  somewhat 
accurately,  of  the  nature  of  bodies  which  come  under  their 
action, — the  difference  between  a  crisp  rusk  and  a  fragment  of 
cinder  being  directly  distinguished,  and  thus  enabling  them  to 
act  as  guardians  to  the  delicate  structures  of  the  alimentary 
canal.  To  determine  the  exact  position  of  the  food  during 
mastication,  it  seems  essential  that  the  teeth  should  be  sensory 
organs  conveying  nervous  influence  by  branches  to  the  same 
centre  that  receives  impressions  from  all  structures  and  parts 
concerned  in  the  process,  viz.,  lips,  tongue,  cheeks,  and  floor 
and  roof  of  mouth,  etc.,  whilst  the  muscles  which  are  concerned 
in  tlie  movements  should  be  controlled  and  harmonized  by  a 
common  centre.  That  the  process  is  almost  purely  a  reflex  one, 
and  can  be  conducted  without  the  aid  of  the  cerebrum,  is  evi- 
denced by  the  manner  in  which  the  act  is  performed  by  ana- 
cephalous  monsters.^  Whatever  the  physiological  explanation 
may  be,  and  we  doubt  not  that  the  foregoing  is  an  approxima- 
tion to  the  truth,  the  practical,  unpleasant  fact  exists  that  den- 
tine is  generally  a  highly  sensitive  structure,  and  in  many 
cases  is  probably  pathologically  hypersesthetic.  It  often  appears 
intensely  sensitive  when  flrst  touched  b}''  an  instrument,  but 
becomes  less  so  after  a  little  time,  which  may  arise  from  the 
nerves  becoming  exhausted  by  frequent  irritation.  Often  when 
it  is  cut  in  one  direction,  say  from  right  to  left,  the  pain  is  un- 

»  Arch.  1,  Mikrosk.  Anat.  iv.  1868. 

2  It  is  an  undoubted  fact,  that  persons  who  have  artificial  teeth  supplied  to 
them  find  at  first  considerable  difliculty  in  ascertaining  -when  their  food  has 
been  sutliciently  comminuted. 


220    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

endurable:  when  the  movement  is  reversed  from  left  to  right  it 
becomes  endurable. 

[It  should  always  be  the  endeavor  of  the  operator  to  prevent, 
as  early  as  possible,  all  painful  impressions  by  severing  all  con- 
nection with  the  pulp  cavity,  using  keen  instruments  to  cut 
at  right  angles  to  the  dentinal  tubuH,  at  the  points  nearest  to 
the  pulp  itself.  He  should,  above  all,  avoid  the  crushing  of  the 
tubuli  longitudinally,  either  toward  or  from  the  pulp,  as  it  is 
an  unbearable  and  unnecessary  torture.] 

Many  applications  have  from  time  to  time  been  advocated  as 
capable  of  reducing  this  sensitiveness  ;  chloroform,  carbolic  acid, 
creosote,  and  aconite,  at  times  mitigate  it'  so  much  as  to  bring  it 
within  bearable  limits,  but  generally  they  have  little  effect  other 
than  that  of  encouraging  the  patient  to  more  endurance.  Where, 
however,  the  sensitiveness  compels  us  to  desist,  we  may  induce 
our  patients  themselves  to  apply  a  solution  of  tannin  in  ethevf 
or  we  may  dress  the  tooth  with  creosote  and  morphia,  covered 
over  with  cotton  steeped  in  mastich-varnish,  which  should  be 
changed  every  four  or  five  days ;  the  spirit  of  the  varnish  leaves 
it,  on  account  of  its  greater  affinity  for  the  fluids  of  the  mouth 
than  for  the  mastich,  which  latter  is  left  incorporated  in  the 
meshes  of  the  cotton,  and  makes  a  useful  temporary  stopping 
for  some  days.  The  application  of  very  small  quantities  of 
arsenious  acid  has  been  recommended,  but  there  is  some  danger 
of  the  pulp  being  compromised  in  the  process,  its  object  being 
the  destruction  only  of  the  contents  of  the  dentinal  tubuli. 
[Arsenious  acid  used  for  this  purpose  has,  however,  destroyed 
so  many  jtulps  tliat  its  employment  is  not  now  practised.]  To 
obviate  the  trouble  and  unpleasantness  of  such  applications  as 
those  above  mentioned,  we  may  resort  to  temporary  fillings. 
Those  varieties  of  gutta-percha  compounds  wiiich  are  most 
readily  softened  by  heat  are  very  serviceable,  and  their  effi- 
cacy may  be  increased  by  placing  them  over  small  disks  of 
card  moistened  with  creosote  or  carbolic  acid.     They  may  be 

'  The  last  we  have  found  the  best.     All  are  applied  oa  very  small  dossils  of 
cotton  to  the  sensitive  surface  only. 
*  I^.  Acidi  tannici,  giij. 
^theris,  .'^j. 
M.  ft.  applieatio. 
To  be  applied  ou  cotton,  and  changed  two  or  three  limes  daily. 


TREATMENT    OF    DENTAL    CARIES.  221 

left  in  from  one  month  to  three  months,  when  the  tooth  will 
probably  be  found  much  less  sensitive.  No  application  that  we 
know  of  attains  the  end  in  view  so  certainly  as  the  oxychloride 
of  zinc,  but  its  api»lication  may  be  attended  with  severe  pain ; 
still  it  can  be  borne  in  most  cases,  and  for  this  the  preparation 
vended  as  Fletcher's  is  the  best;  for,  not  containing  any  har- 
dening foreign  material,  it  is  much  the  easiest  to  remove,  which 
should  be  done  after  one  to  three  months. 

[The  actual  cautery  by  a  coal  of  lire  on  the  end  of  a  piece  of 
pivot  wood,  touching  only  for  an  instant  at  a  time,  but  often  re- 
peated, first  using  only  the  ash,  and  gradually  increasing  the  heat 
to  an  incandescent  coal  by  raiiidly  moving  the  stick  through  the 
air, — will  burn  out  all  superficial  sensitiveness.^  Pure  nitric  acid 
on  a  match  stick  is  occasionally  of  service  in  posterior  teeth, 
but  great  care  must  be  exercised  to  use  very  minute  quantities, 
and  as  soon  as  the  work  is  done  to  neutralize  the  acid  with 
chalk,  ammonia  water,  or  other  alkali.  If  these  means  fail  or 
are  impracticable,  resort  may  be  had  to  general  anaesthesia.] 

However  careful  we  may  be  in  removing  the  softened  den- 
tine, we  at  times  cannot  avoid  exposing  the  dental  pulp,  espe- 
cially when  it  is  abnormally  situated,  as  is  occasionally  the 
case  in  upper  incisor  teeth.  The  pain  inflicted  generally,  but 
not  always,  indicates  to  us  what  has  hap[iened,  and  the  cavit}' 
of  the  tooth  becomes  filled  with  blood.  The  blood  being 
staunched  with  a  little  carbolic  acid  or  solution  of  tannin, 
and  the  cavity  having  been  comjileted,  a  small  cap  of  metal 
of  concavo-convex  form  may  be  laid,  the  concave  surface  over 
the  exposed  spot,  and  the  filling  completed  as  if  no  such  occur- 
rence had  happened.  Instead  of  metal  (gold,  tin,  lead)  quill 
or  card  caps  may  be  used,  or  we  m;iy  touch  the  exposed  spot 
with  strong  nitric  acid,  and,  without  capping,  fill  over  with 
foil,  taking  care  so  to  place  a  large  and  firm  cylinder  over  the 
exposed  spot,  that  it  may  be  condensed  without  touching  the 
pulp.2       . 

[The  editor  would  suggest-  the  use  of  chips  or  powder  from 
tlie  healthy  dentine  of  the  tooth  itself,  made  b}-  scraping  the 

['  See  American  Journal  of  the  Medical  Sciences,  p.   561,  April,  1877;  or 
Johnston's  Dental  Miscellany,  p.  155,  April,  1877.] 
2  The  practice,  we  believe,  ofBogue,  of  New  York. 


222    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

walls  of  the  cavity  upwards  towards  the  point  of  exposure,  and 
covering  it  with  the  powdered  dentine,  then  covering  with  a 
gutta  percha  cap.  It  is  claimed  that  much  of  the  success  in  pulp- 
capping  may  be  owing  to  tliis  process  having  been  followed  in- 
advertently. The  theory  is  based  upon  the  general  principle  of 
grafting,  recently  so  highlj-  recommended  in  healing  ulcerated 
surfaces  of  the  skin.  This  dentine  certainly  does  make  the  most 
natural  non-conducting  cover.  In  all  cases  of  closing  w^ounds,  it 
is  well  to  await  the  glazing  over  of  the  surface  by  the  13'raph 
undergoing  coagulation,  and  when  this  takes  place,  the  chips  or 
powder  will  readily  adhere  to  the  surface.  So-called  medication 
with  carbolic  acid,  tannin,  and  other  articles  has,  at  least,  to  be 
defended  against  the  charge  of  introducing  foreign  bodies  into 
the  wound,  a  practice  which  savors  of  an  age  in  surgery  happily 
long  passed.  We  should  avoid  an  imposition  upon  nature, 
which  would  require  her  to  throw  off  foreign  matter,  in  addi- 
tion to  healing  the  wound.  It  may  be  added  that  even  if  the 
scraped  dentine  be  dead,  it  is  at  least  the  nearest  in  condition 
to  the  natural  pulp-capping  of  any  material  that  can  be  used, 
and  is  likewise  most  convenient  and  ready  for  application.] 

The  ])rocess  of  capping  is  likewise  employed  with  advantage 
wherever  the  disease  has  so  far  encroached  upon  the  pulp  that 
we  have  reason  to  suspect  that  only  a  thin  layer  of  dentine  in- 
tervenes, and  where  the  irritation  of  a  metallic  filling,  through 
such  close  proximity  or  changes  of  temperature,  might  lead  to 
irritation,if  not  destruction,  of  that  organ:  this  protection  is  espe- 
cially desirable  in  the  treatment  of  the  teeth  of  young  persons. 

But  the  pulp  may  have  become  ex[)Osed  in  the  progress  of 
the  disease,  and,  when  this  is  the  case,  its  surface  is  almost  in- 
variably found  to  present  an  ulcerated  condition,  most  difficult 
to  be  made  to  heal  over,  and  excreting  a  thin  sanious  and 
offensive  fluid,  most  resembling  perhaps  the  [)uriform  fluids 
exuded  from  gangrenous  parts.  As  betbre  noticed  (see  p.  120), 
this  fluid  is  commonly  spoken  of  as  {»us ;  but,  altlwugh  pus 
may  sometimes  be  found  in  the  pulp-cavity,  it  differs  greatly 
from  that  bland,  cell-formed  excretion.  Whilst  the  ulcerated 
surface  of  the  pulp  continues  to  excrete  this  or  any  other  fluid, 
no  attempt  to  hermetically  close  up  the  cavity  must  be  at- 
tempted ;  for  the  fluid,  continuing  to  form,  and  having  no  out- 
let, would  press  back  upon  the  pulp,  and  those  painful  condi- 


TREATMENT    OF    DENTAL    CARIES.  223 

tions,  generally  culminating  in  severe  alveolar  abscess,  would 
ensue,  which  are  but  too  well  known  to  patients  as  well  as  to 
practitioners.  A  few  years  ago  it  was  the  general  custom  to 
treat  by  destruction  almost  all  cases  of  exposure  of  tlie  pulp  by 
disease,  and  not  a  few  even  of  those  of  exposure  by  the  excava- 
tor. The  process  is  a  convenient  one  to  the  practitioner,  as  it 
leaves  a  tooth  which  may  be  afterwards  excavated  without  sen- 
sation into  any  requisite  convenient  shape  for  tilling.  Expe- 
rience, however,  having  proved  that  a  large  percentage  of  such 
cases  do,  after  a  time,  become  liable  to  periodontal  irritation  and 
inflammation  with  its  results,  more  conservative  plans  have 
been  adopted,  and,  when  those  have  failed,  there  is  generally 
the  dernier  ressort  left,  of  destruction  of  the  pulp.  Since  the 
introduction  of  carbolic  ac^^  and  the  zinc  oxychlorides,  a  larger 
number  of  pulps  have  no  doubt  been  preserved,  and  with  con- 
siderable comfort  to  the  patient.  The  proceeding  consists  in 
removing  all  the  softened  dentine,  and  then  well  dosing  the 
exposed  pulp  with  carbolic  acid  ;'  over  the  pulp  is  then  placed  a 
cap  of  thin  address-card  or  stiff  paper,  also  moistened  with  car- 
bolic acid,  and  this  is  covered  b}-  a  larger  cap,  coated  on  one 
side  with  mastieii-varnish  to  cause  it  to  adhere,  and  also  to 
prevent  any  of  the  oxychloride  from  reaching  the  pulp,  with 
which  compound  the  tilling  is  completed.  If  such  a  filling  be 
removed  after  some  months,  the  pulp  may  be  found  exposed, 
living,  and  free  from  discharge;  or  it  ma}^  be  found  still  ex- 
posed and  discharging,  in  which  case  the  discharge  has  relieved 
itself  into,  and  even  through,  the  i)orons  oxychloride,  which 
will  be  found  saturated  with  it;  or  it  may  be  found  to  have 
lost  its  vitality.  Under  the  first  conditions  it  may  now  be 
capped  over  and  filled  permanently  ;  under  the  second,  the  pro- 
cess must  be  repeated  or  the  pulp  destro^-ed  ;  under  the  third, 
the  dead  pulp  must  be  removed,  and  the  fangs,  as  well  as  the 
pulp-cavity,  filled  in  the  metliod  to  be  shortly  described.  For 
some  years  we  have  adopted  a  plan  which  has  yielded  excellent 
results,  and  by  means  of  which  the  pulp,  and  consequently  the 
vitality  of  the  tooth,  is  preserved,  whilst  the  tooth  is  perma- 

'  A  good  form  is  the  pure  crystallized  acid,  rendered  fluid  by  a  few  drops  of 
cliloroform.  [It  may  be  introduced  as  a  crystal,  and  the  heat  of  the  tooth  will 
melt  it,  but  the  pellicle  of  carbolized  pulp  is  not  as  likely  to  form  a  normal 
covering  as  the  natural  lymph.] 


224    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

nentlj  filled  at  the  same  time;  and  it  is  more  especially  suited 
to  cases  in  which  the  exposed  pulp,  say,  of  a  molar  tooth,  is 
found  of  a  crimson  color,  freely  exposed,  and  even  granulating 
into  the  carious  cavity  bej'oiid  the  pulp-cavity, — an  early  stage 
of  polypus  of  the  pulp,  and  a  condition  in  which  the  attempt  at 
preservation  by  carbolic  acid  is  seldom  successful,  and  destruc- 
tion by  arsenious  acid  often  tedious  and  uncertain.  The  soft- 
ened dentine  having  been  cleared  away,  and  the  cavity  other- 
wise prepared,  the  sensitiveness  of  the  exposed  pulp  is  lessened 
by  a  free  application  of  carbolic  acid,  and  then  a  small  disk  of 
card,  but  little  larger  than  the  exposed  surface,  and  well  satura- 
ted with  the  strongest  nitric  acid,  is  laid  gently  upon  it,  and  so 
retained  for  about  half  a  minute:  at  times  a  sensation  like 
tooth-ache,  but  never  severe,  is  fel^  for  a  few  minutes  after- 
wards. After  removal  of  the  nitric  acid,  a  cap  of  thick  paper, 
moistened  with  carbolic  acid,  is  placed  over  the  pulp,  and,  if 
the  tooth  is  to  be  tilled  with  foil,  over  the  paper  cap  one  of 
metal,  concave  on  the  pulp  surface,  to  guard  the  pulp  from  all 
pressure:  the  filling  is  then  completed  as  if  no  exposure  of  the 
pulp  had  existed.  The  same  process  may  be  adopted  in  the 
case  of  an  amalgam  filling,  but  it  will  be  found  a  good  plan  to 
give  a  coating  of  oxychloride  over  the  first  paper  cap  in  the 
place  of  the  metal  one ;  and  this  is  best  done  by  keeping  such 
caps  in  readiness,  as  there  is  then  no  danger  of  moist  oxychlo- 
ride getting  access  to  the  pulp.  The  oxychloride  being  an  in- 
ferior conductor  of  heat  to  metal,  there  will  be  less  chance  of 
irritation  due  to  changes  of  temperature.  In  almost  all  cases 
where  we  have  had  the  opportunity  of  seeing  the  result  of  this 
treatment,  we  have  found  the  pulp  alive  and  apparently  healthy, 
but  never  calcified. 

In  the  place  of  nitric  acid  the  actual  cautery  may  be  em- 
ployed (Fig.  213),  the  best  form  being  the  galvanic,  in  which  a 
bent  platina  wire  is  maintained  at  a  white  heat.  After  de- 
stroying a  portion  of  the  surface  of  the  pulp  by  the  heated  wire, 
we  proceed  as  in  the  treatment  after  the  application  of  nitric 
(icid. 

"We  have  spoken  of  hypertrophy  of  the  pulp  when  exposed 
by  disease.  In  many  cases,  especially  those  of  extensive  caries 
on  masticating  surfaces,  the  pulp  becomes  enlarged  to  several 
times  its  own  normal  dimensions,  extending  to  the  level  of  the 


Fis.213. 


TREATMENT  OF  DENTAL  CARIES, 
Fi£:.  213. 


22") 
Fi?.  214. 


g  The  galvanic  cautery.    The  portion  held  in  the  hand  is  constructed 

"  of  ivory,  and  Insulates  the  wires  from  the  battery,  which  terniiuate 

I  in  a  loop  of  fine  platina  wire  :  the  latter  becomes  white  hot  when 

J  the  battery  is  in  action. 

o 

I     crowns   of  adjoining   teeth.     It    presents    a 
i     pale  rose  color,  and  is  tender  when  pressed 
I     upon,  but  not  nearly  as  n.uch  so  as  an  ordi- 
I     narily  exposed  pulp;  it  bleeds  freely  Avhen 
i     touched,  and  excretes  a  fluid  of  most  ofl^en- 
I     sive  odor,  often  tainting  the  breath  considera- 
I     bly.     A  section  shows  its  surface  to  be  cov- 
I     ered  with  very  regularly  arranged   papillae, 
but  we  have  not  been  able  to  make  out  any 
special  secreting  glands.     In  most  cases  the 
teeth  thus  aifected  are  too  far  destroyed  to 
induce  us  to  attempt  their  preservation,  but, 
in  cases  where  it  has  been  considered  worth 
while,  we  have  generally  by  the  following 
plan  succeeded.     We  first  dose  the  growth 
with  carbolic  acid  to  deaden  its  sensitiveness, 
and  then,  witii  a  scythe-shaped  lancet,  cut 
away  as  much  of  it  as  possible.     After  the 
bleeding  has  ceased,  we  carry  out  precisely  the  nitric  acid  pro- 
cess above  described. 

When  it  is  deemed  exi)edient  to  destroy  the  pulp,  this  may 
15 


226        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

be  effected  immediately  or  mediately.  The  former  is  only 
suitable  in  cases  where  the  pulp  can  be  easily  reached,  notably 
in  cases  of  fractured  single-fanged  teeth.  A  thin  barbed  in- 
strument of  soft  steel  (Fig.  212)  is  passed  along  the  pulp  to  its 
extremity,  rotated  and  withdrawn,  bringing  with  it  the  contents 
of  pulp  and  fang  cavities.  [In  applying  the  broach,  care  should 
be  used  that  the  barbed  side  is  next  to  and  against  the  walls  of 
the  pulp-chamber  when  pushing  it  up,  as  thus  less  pain  is  in- 
flicted.] It  is  mostly  an  intensely  painful  process  without  an 
ansesthetic.  A  white-hot  steel  instrument  causes  much  less 
pain,  as  does  also  a  fine  sjJinter  of  wood  previously  dipped  in 
strong  nitric  acid.  In  most  cases  we  resort  to  the  mediate 
process,  which  consists  in  applying  some  strong  escharotic,  as 
chloride  of  zinc,  nitrate  of  silver,  or  caustic  potash,  or  irritant, 
such  as  arsenic,  to  the  surface  of  the  pulp.  The  latter  is  the 
agent  most  employed,  and  the  process  is  best  accomplished  as 
follows:  The  softened  dentine  being  removed,  it  is  essential  to 
have  the  pulp  freelj^  exposed,  and,  although  the  process  is  pain- 
ful, it  is  little  to  the  agony  experienced  when,  from  insufficient 
exposure,  the  inflamed  and  swelling  pulp  becomes  compressed 
in  the  unyielding  pulp-cavity  ;  the  frequent  application  of  car- 
bolic acid  generally  renders  it  tolerable,  whilst  it  at  tlie  same 
time  staunches  the  bleeding.  Upon  the  pulp,  now  freely  ex- 
posed, is  gently  laid  a  small  disk  of  card,  saturated  with  car- 
bolic acid,  and  having  attached  to  its  pulp-surface  about  -Jq-  to 
tV  of  a  orrain  of  pure  arsenious  acid.  The  moistened  card 
readily  takes  up  the  acid  when  laid  ujion  it. 

[While  it  is  most  certainly  preferable  to  cut  away  the  over- 
lying dentine,  the  operation  must  not  infrequently  be  dispensed 
with,  until  after  the  devitalization  of  the  jiulp,  on  account  of 
the  pain  inflicted. 

Arsenic  may  be  combined  w^ith  morphia  and  carbolic  acid  to 
form  a  convenient  paste,  for  which  there  are  various  formulas. 
Prof.  J.  Foster  Flagg's  is  very  generally  used  : — 

I^ — A.rsenic,  grains  j. 

Acetate  of  morphia,  grains  ij. 
Carbolic  acid,  drops  iij.] 

The  cavity  is  now  lightly  but  carefully  filled  up  with  a  little 
beeswax   softened  by  heat.      The  patient  should    be  seen  the 


TREATMENT    OF     DENTAL    CARIES.  227 

next  day,  and,  on  removal  of  the  wax  and  card,  the  pulp  will 
he  generally  found  free,  or  almost  free,  from  sensitiveness,  al- 
though it  not  unfreqnently  hleeds  freely  when  the  iine-harhed 
nerve-extractors  are  inserted  into  the  fang-cavities,  gently  ro- 
tated, and  withdrawn,  having  attached  to  them,  it  may  be  hoped, 
the  contents  of  the  fang-cavities,  all  of  which  should  be  thor- 
oughly removed.  Should  the  patient  not  be  seen  again  for 
some  days  after  the  application  of  the  arsenic,  the  pulp  will 
probably  be  found  softened,  devitalized ,  and  not  vascular.  Some 
deem  it  very  important  that  the  patient  should  be  seen  the 
next  day,  having  a  fear  that  the  arsenic  may  in  time  get  access 
to  the  system,  a  view  tiie  absurdity  of  which  is  manifest  when 
we  recollect  that  tlie  amount  applied,  and  locally  to  a  structure 
destitute  of  absorbents,  is  seldom  more  than  the  full  dose  ad- 
ministered to  a  patient  internally  in  the  course  of  a  day,  and 
hears  no  comparison  to  the  quantities  applied  externally  in  the 
destruction  of  a  malignant  growth.  ^Nevertheless  due  care 
should  be  exercised  that  none  of  the  agent  finds  its  way  directly 
to  the  month.  In  cases  when  the  patient  cannot  be  seen  for 
some  weeks  after  the  application  of  the  arsenic,  it  will  be  best, 
after  placing  it  upon  the  pulp,  to  cover  it  with  a  concave  metal 
cap,  and  then  fill  over  with  Hill's  gutta-percha  stopping;  cases 
thus  treated  often  remain  well  for  years.  Arsenious  acid  has 
]>robably  two  kinds  of  action  when  applied  to  soft  living  tissues; 
one,  escharotic,  in  which  it  destroys  vitality  by  forming  com- 
pounds with  their  albuminous  constituents;  and  the  other,  as 
a  powerful  irritant,  exciting  severe  inflammation;  and  it  is 
generally  believed  that  it  is  chiefly  the  latter  action,  which, 
terminating  in  sphacelus,  causes  destruction  of  vitality  in  the 
dental  pulp.  Arsenious  acid  has  also,  as  is  well  known,  a 
powerful  antiseptic  action,  and  is  unequalled  in  preventing  for 
lengthened  periods  the  decom[»osition  of  animal  substances  ; 
hence  the  pulp,  though  destroyed,  is  seldom  found  putrid  after 
its  action,  and  this  property  may,  as  we  shall  see,  be  turned  to 
good  account  in  certain  troublesome  cases.  To  resume:  the 
fang-cavities  being  cleared  out, — no  easy  matter  in  the  case  of 
lower  molars, — they  should  be  filled  up,  and,  though  gold  may 
be  employed  in  certain  easy  cases,  it  is  better  to  use  the  oxy- 
chloride  of  zinc,  mixed  rather  fluid,  and  incorporated  with  finely- 
chopped  cotton-wool;  this  must  be  worked  into  the  fangs  by  a 


228    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

sort  of  pumping  action,  by  which  means  the  air  is  pressed  out 
and  the  stopping  pressed  in  ;  the  oxychloride  being  powerfully 
antiseptic,  little  hurt  is  likely  to  accrue  if  any  small  particles  of 
soft  tissue  be  left  in  the  fang-cavities.  If  gold  be  used,  it  is 
well  to  wash  out  the  fang-cavities  with  carbolic  acid  or  creasote 


Fi-.  215. 


Fiir.  216. 


I 

Form  of  instruments  for  remov- 
ing the  disorganized  concents  of  a 
pulp-cavity. 


Pluggers  of  a  delicate  form  for  filling  the  fang 
cavities  with  foil. 


before  attempting  to  insert  it.  [At  this  stage  of  the  operation 
there  seems  to  be  no  question  that  the  use  of  pure  carbolic  acid 
in  crystals  is  the  best  means  of  disposing  of  the  fine  filaments 
and  the  vessels  within  the  apex  of  the  root.] 

Occasionally,  though  rarely,  and  more  especially  in  single-fang 
teeth,  we  may  find  that  the  pulp  has  undergone  a  species  of  dry 
gangrene,  and  on  removal  appears  free  from  unpleasantness,  and 
of  a  pithy  consistency  ;  the  tooth  has  not  changed  color,  and 
the  periodontal  membrane  appears  perfectly  healthy,  showing 
that  the  tooth,  though  possessing  no  vitality  except  probably 
at  its  cementum,  is  no  cause  of  irritation  to  surrounding  tissues. 
In  other  cases  we  may  find  that  the  whole  of  the  dental  pul[) 
has  sloughed  away,  leaving  the  surrounding  dentine  softened, 
but  not  putrid,  both  of  which  classes  of  cases  we  should  treat 
precisely  as  if  we  had  removed  the  pulp.  It  may,  however, 
happen  that,  whilst  the  pulp  has  sloughed  away,  the  canal-cavi- 
ties are  filled  with  puriform  t^uids,  the  dentine  itself  being  moist 
and  very  ofi'ensive;  and  it  is  rare  to  find,  in  such  cases,  freedom 
from  periodontal  irritation,  caused  no  doul)t  by  the  presence  of 
septic  substance.     Such  cases  have  been  usually  treated  by  the 


TREATMENT    OF    DENTAL    CARIES.  229 

frequent  application  of  strong  antiseptics,  carbolic  acid  and 
creasote,  alone,  or  mixed  with  iodine,  being  the  favorites  ;  but 
for  some  years  we  liave  employed  arsenious  acid,  as  with  one 
application  we  have  obtained  more  certain  results  than  with 
ten  or  twenty  applications  of  those  above  mentioned  :  we  sim- 
}ily  clear  out  the  pulp-cavity,  wash  out  with  carbolic  acid,  and 
apply  the  arsenic  precisely  as  if  for  destruction  of  a  pulp,  laying 
the  application  over  the  orifice  or  orifices  of  the  fang-cavities, 
and  then  filling  over  with  oxychloride  of  zinc.  If  the  latter 
be  removed  after  two  or  three  months,  the  pulp  and  fang-cavi- 
ties will  generally  be  found  dry  and  perfectly  sweet;  indeed, 
we  believe  that  there  is  really  no  necessity  for  fang-filling  in 
these  cases,  as  the  arsenic  effectually  renders  their  contents  in- 
capable of  further  decomposition  ;  but  upon  this  point  we  would 
speak  with  reserve. 

[Prof.  Flagg  has  recommended  that  the  arsenical  paste  (p.  226) 
be  pricked  into  the  canals  by  slow  movements  of  a  fine  broach 
toward  the  a]»ex,  and  even  at  one  sitting  the  contents  may  be 
removed  with  little  more  pain  than  an  occasional  pin-scratch 
would  give. 

To  impress  upon  the  reader  the  difference  of  action  of  the 
two  classes  of  antiseptics,  the  following  extracts  from  a  paper 
on  the  subject  by  Prof.  Wilbur  F.  Litch  are  here  offered.^ 

"All  antiseptics,  when  applied  in  sufiicient  strength,  have 
the  power  of  destroying  minute  organisms,  and  of  thus  arrest- 
ing fermentative  and  putrefactive  changes ;  but  a  careful  dis- 
crimination must  be  made  between  the  powers  respectively  of 
such  antiseptics  as  carbolic  acid,  creasote,  oil  of  cloves,  etc., 
and  such  other  antiseptics  as  chlorine,  bromine,  iodine,  etc., 
Avhich,  in  addition  to  their  antiz^anotic  power,  are  true  chemi- 
cal antagonists  of  those  sulphuretted  hydrogen  compounds  of 
which  putrefactive  gases  are  constituted,  such  gases  being 
immediately  decomposed  by  them,  their  hydrogen  element 
going  either  to  tiie  chlorine,  bromine,  or  iodine,  to  form  respect- 
ively hydrochloric,  hydrobromic,  or  hydriodic  acid,  the  suljihur 
Ijeing  in  each  case  [)i'ecij)itate<l." 

"In  the  antiseptic  treatment  of  putrescent  pulp-canals,  great 
advantage  is  to  be  derived   from  a  dressing  composed  of  car- 

['  See  Pennsylvania  State  Dental  Society  Transactions,  1881.] 


230    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

bolic  acid  or  creasote  and  iodine.  By  the  use  of  this  combination, 
not  only  is  putrefaction  arrested,  but  its  products  are  decom- 
posed, each  molecule  of  the  putrefactive  gas  being,  as  it  is  formed, 
Beized  by  the  iodine,  and  its  elements  forced  into  such  other 
combinations  as  shall  render  them  incapable  of  exercising  pres- 
sure under  the  conditions  ordinarily  present  in  the  pulp-cham- 
ber of  a  devitalized  tooth." 

The  following  formula  is  recommended: — 

B — lodinii  (crystals), 

Acidi  carbolici  (crystals),  aa  5j- 
Alcobolis,  f3ij.     M. 
Sig.    Saturate  "witli    this  mixture  a  pledget  of  cotton  of  suitable  size,  aud 
place  in  the  pulp-canal  (previously  cleansed)  of  the  tooth  to  be  treated.] 

We  have  thus  treated  many  cases  permanently  at  the  first 
sitting,  and,  so  far  as  time  luis  permitted,  we  may  speak  most 
favorabl}'  of  the  results.  In  such  cases  only  part  of  the  cavity 
has  been  filled  with  the  oxychloride,  the  remainder  with  foil  or 
amalgam.  In  very  many  of  the  cases  slight  periodontal  irrita- 
tion, which  previously  existed,  has  disappeared,  the  teeth  be- 
coming again  fully  serviceable  for  mastication.  In  treating 
upon  the  subject  of  discharging  pulps,  the  student  cannot  be 
too  forcibly  impressed  Avith  the  importance  of  always  ascer- 
taining whether  such  condition  exists  previous  to  inserting  a 
filling  into  a  tooth:  the  cavity  may  deceive,  from  being  shal- 
low and  at  a  distance  from  the  pulp,  and  may  yet  communicate 
with  it  by  a  very  fine  channel.  Daring  the  progress  of  excava- 
tion, clean  cotton -wool  should  be  more  than  once  introduced 
into  the  cavity,  and,  when  it  has  been  removed,  the  sense  of 
smell  will  seldom  fail  to  detect  any  existence  of  discharge. 
Liability  to  the  opposite  error  may,  however,  arise  in  cavities 
close  to,  or  below,  the  gum,  where  the  latter  has  bled  and  its 
serum  become  decomposed  in  the  cavity,  when  the  same  stench 
is  afforded.  In  such  doubtful  cases  the  cavity  may  be  purified 
by  permanganate  of  potash,  and  then  after  a  little  time  fresh 
cotton  applied,  which  will  be  sweet  or  otherwise,  according  as 
discharge  exists  or  not.  A  ready  but  less  perfect  means  of 
treating  cases  where  discharge  exists  in  the  fang-cavities,  con- 
sists in  capping  over  the  pul[i-ciivity,  and  at  once  filling  the 
tooth,  after  which  a  fine  hole  is  drilled  either  through  the  side 


TREATMENT  OF  DENTAL  CARIES, 


231 


Fig. 217 


of  the  tooth  just  below  and  through  the  margin  of  the  gum,  or 
through  the  tilling  itself  into  the  puljtcavity  :  the  process  of 
decay,  though  not  whollj^  arrested,  is  tlins  very  much  retarded, 
whilst  the  discharge  obtains  a  free  outlet,  and  generally  after  a 
few  years  ceases  to  be  secreted.  [This  is  probably  only  justifia- 
ble in  teeth  of  aged  persons  who  may  not  have  the  prospect  of 
very  long  need  of  them,  and  yet  who  are  not  likely  to  be  under 
the  inconvenience  of  learning  to  use  artificial  ones.] 

The  same  process  may  be  adopted  when  pain  comes  on  after 
a  tooth  has  been  filled,  especially  if  it  be  conjectured  that  the 
pulp  has  perished,  when  the  gases  and  fluids 
generated  will  obtain  an  outlet.*  Ilullihen  has 
recommended  our  doing  so  in  cases  where  we 
may  believe  the  pulp  to  be  still  living:  we  have 
drilled  into  the  living  pnl[>  on  a  few  occasions, 
and  on  the  whole  with  l)enefit  to  the  j)atients, 
thereby  no  doubt  relieving  the  tension  of  the 
organ. 

In  most  cases,  how^ever,  where  pain  is  set  uj)  in 
a  tooth  that  has  been  filled,  especially  if  it  be  con- 
stant and  increasing,  we  shall  do  best  to  remove    suitable  for  drui- 

,  .  ,      ^  .  .p  .,   ,         .  ing  into  the  pulp- 

the  stopping,  and  ascertain,  it  possible,  its  cause,  cavity  of  a  tooth. 
We  may  find  that  exposure  of  the  pulp  at  a  cer- 
tain spot  existed,  and  has  been  overlooked,  for  it  is  quite  possi- 
ble for  a  pulp  to  be  exposed  and  yet  excrete  no  unpleasant  dis- 
charge, as  we  have  occasionally  found  to  be  the  case.  It  may 
prove,  as  in  the  case  of  amalgams  especially,  that  changes  of 
temperature  readily  conducted  through  them  have  led  to  irrita- 
tion of  the  not  far  distant  pulp;  or  even,  in  the  case  of  an  amalgam 
which  ex[>ands  slightly  in  setting,  the  adjoining  dentine  may 
have  thus  sutfered  from  [iressure.  In  the  two  latter  cases,  the 
substitution  of  a  gutta-percha  filling,  for  a  time,  in  the  place  of 
the  metallic  one,  will  be  the  safest  course  to  [lursue. 

Pain,  of  a  moderate  amount,  may  come  on  at  intervals  in  a 
tooth  in  which  we  maj'  have  good  reason  to  believe  tluit  none  of 
the  above-mentioned  causes  exist.  Coming  into  a  warm  room, 
suddenly  moving  the  head,  as  in  stooping  or  going  down  stairs; 


Drills  to  be  em- 
ployed with  till' 
dental     engine, — 


'  An  operation  more  than  a  century  old,  and  now  most  readily  accomplished 
by  the  bur-engine. 


232    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

and  also  being  exhausted  or  fatigued,  especially  during  fasting, 
may  seem  to  excite  it.  Under  such  conditions  we  may  surmise 
that  the  .pulp  is  subject  to  occasional  congestions,  the  explana- 
tion, we  presume,  of  what  is  termed  an  irritable  pulp.  For  the 
relief  of  these  cases  we  have  found  no  class  of  remedies  so  serv- 
iceable as  counter-irritants,  and  that  which  we  most  employ  is 
a  saturated  solution  of  chloride  of  ammonium  in  water,  rubbed 
upon  the  surrounding  gum.  Experiment  has  shown  that  for  a 
considerable  distance  below  the  spot  at  which  a  blister  has 
been  applied  the  various  structures,  and  not  essentially  all  of 
those  which  receive  their  blood  from  the  same  source,  are  more 
anaemic  than  normal,  which  explains  the  action  of  counter-irri- 
tants in  relieving  congestion.  [Saturated  tincture  of  iodine 
will  blister  nicely.  The  gum  should  be  dried,  and  a  pellet  of 
cotton  saturated  with  the  tincture  applied  on  the  part  over- 
lying the  root  of  the  tooth.] 

Many  other  conditions  not  enumerated  will  at  times  crop  up, 
to  interfere  with  or  even  defeat  the  best  and  most  patient 
elibrts  of  the  operator.  Cramp  in  the  jaws,  from  wide  distension, 
is  a  trouble  from  which  some  patients  suffer  much,  at  times 
relieved  by  their  having  a  prop  to  bite  upon,  which  is  often  a 
comfort  also  to  those  whose  mouths  are  kept  long  open.  Very 
small  mouths,  or  rather  mouths  Avith  very  small  openings,  con- 
siderably obstruct  an  operator ;  but  that  which  is  perhaps  worse 
than  any  of  the  above-mentioned  peculiarities,  is  the  tendency 
of  some  patients  to  faint  as  soon  as  an  operation  is  attempted: 
we  have  best  succeeded  with  these  at  an  early  period  of  the 
day,  i.  e.,  soon  after  breakfast  and  the  night's  rest. 

The  teeth  of  very  young  people,  however  carefully  filled, 
have  a  strong  tendency  to  an  extension  of  the  mischief  around 
the  fillings.  We  have  seen  some  of  the  most  excellent  fillings 
fail  thus,  though  made  by  operators  of  the  highest  reputation. 
We  believe  that  it  will  be  found  good  practice  to  fill  the  teeth 
of  these  first  with  either  the  zinc-chlorides  or  zinc-phosphates, 
which,  probal)ly  from  their  making  perfectly  water-tight  fill- 
ings, have  a  tendency  to  harden  the  tooth  in  the  neighborhood 
of  the  filling.  In  strong  teeth,  though  it  be  very  desirable,  it 
is  not  absolutely  iniperative  that  a  filling  should  be  perfectly 
water-tight.  If  we  select  from  amongst  the  teeth  which  we 
have  removed  some  which  have  been  filled  with  gold  or  anialgam 


TREATMENT    OF    DENTAL    CARIES.  233 

for  a  number  of  years,  and  in  which  the  fillings  still  appear 
quite  perfect,  and  immerse  them  for  some  time  in  a  colored  fluid 
which  is  a  chemical  compound,  i.  e.  not  merely  a  colored  body 
held  in  suspension, — Draper's  ink  answers  the  purpose  very 
^vell, — we  shall,  on  removing  the  teeth,  and  splitting  them 
across  the  filled  spots,  almost  invariably  find  that  the  color  has 
penetrated  between  the  stopping  and  the  cavity.  It  would  seem, 
therefore,  that  the  presence  of  more  solid  substance  is  essential, 
in  strong  teeth  at  least,  to  the  progress  of  caries,  which  favors 
the  opinion  we  have  expressed  with  regard  to  it  (see  p.  128). 
[There  must  be  some  allowance  made  in  this  experiment  for  the 
shrinkage  of  the  tooth  from  drying,  and  of  the  filling  from 
difference  of  temperature.] 

In  those  whose  teeth  have  on  the  whole  stood  well,  changes 
in  the  constitution  may  have  a  great  effect  for  the  worse,  and 
amongst  these  pregnancy  is  undoubtedly  the  most  common. 
"Women  who  have  had  excellent  teeth  up  to  the  period  of  a  first 
])regnaney,  often  lose  them  one  after  another,  and  usually  with 
considerable  suffering,  especially  if  a  family  come  very  fast. 
Various  explanations  have  been  offered,  none  of  which  appear 
to  us  80  satisfactory  as  that  the  secretions  of  the  mouth  are 
altered  in  character,  and  the  teeth  have  their  power  of  resist- 
ance lessened.  Again,  we  have  seen  teeth  in  young  persons, 
which  we  have  pronounced  excellent,  become  completely'  altered 
in  character  after  an  attack  of  one  of  the  exanthemata,  especially 
scarlatina.  Great  mental  strain  is  another  cause  of  teeth  taking 
on  sudden  and  rapid  decay,  and  this  is  well  illustrated  in  the 
case  of  those  who  have  been  working  for  some  time  for  severe 
competitive  examinations.  A  visit  abroad,  notwithstanding 
the  general  good  done  to  the  system,  often  has  a  deleterious 
infl.uence  upon  the  teeth,  and  a  short  residence  in  Switzerland 
is  so  marked  in  this  respect,  that  we  cannot  but  believe  it  to  be 
due  to  certain  local  conditions,  probably  the  water.  On  the 
other  hand,  a  residence  in  some  countries  lias  the  opposite 
effect,  and  we  believe  we  may  say  without  contradiction,  that 
residence  for  a  time  in  India  or  China,  the  former  especially, 
proves  beneficial  to  these  organs.  In  treating  teeth  which  have 
sufi'ered  from  the  above-mentioned  causes,  we  shall  find  the 
ordinary  metallic  fillings  most  unsatisfactory,  and  we  shall  em- 
ploy to  most  advantage  the  zinc-phosphate  or  gutta-percha,  until 


234   MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

we  can  conclude  that  the  ahnormal  conditions  have  to  a  great 
extent  passed  off.  A  most  careful  employment  of  the  tooth- 
brush after  every  meal  must  he  inculcated,  and  the  ammonia 
and  spirit-mixture  spoken  of  (see  p.  43)  may  be  used  with  ad- 
vantage. 

[Chalk  ma}^  be  freely  applied  by  the  finger  around  the  teeth 
on  retiring,  and  lime-water  used  to  wash  it  away  in  the  morning. 
This  will  at  least  modify  the  local  conditions,  but  the  general 
health  and  appetite  should  never  be  lost  sight  of.  Fresh  air,  exer- 
cise, regular  meals  of  healthy,  substantial  food,  such  as  bread  made 
from  unbolted  flour,  fresh  meat,  particularly  that  of  small  birds, 
the  bones  of  which  should  be  eaten  ;  lobsters,  crabs,  oysters,  and 
every  form  of  food  containing  lime,  together  with  milk  and  lime- 
water,  will  bring  about  an  improvement  in  the  tooth-structure.] 

In  the  present  chapter  we  have  incidentally  spoken  of  almost 
all  the  abnormal  conditions  which  may  occur  to  the  dental  pulp. 
Some  writers  have  considered  it  desirable  to  attempt  to  classify 
them,  and  to  define  each  at  some  length.  We  believe  such  at- 
tempt to  be  more  likely  to  confuse  the  dental  student  than  to 
aid  him,  at  least  in  his  practical  work  ;  his  treatment  of  a  tooth 
will  probably  never  be  influenced  b}'  his  considering  the  ques- 
tion,— is  the  pulp  in  this  case  in  a  congested  condition  onlj^  or 
may  it  be  in  a  state  of  chronic  inflammation?  He  can  obtain 
but  at  most  a  very  imperfect  knowledge  of  its  condition,  en- 
closed as  it  is  in  its  bony  surroundings,  unless  it  be  at  some  s[>ot 
exposed  to  view,  and  he  will  then  act,  in  nine  out  of  ten  in- 
stances, according  to  the  appearance  that  it  presents,  whether 
for  its  preservation  or  for  its  destruction.  If  for  the  purposes 
of  an  examination  such  knowledge  be  deemed  requisite,  we 
would  simply  remind  the  student  that  the  dental  pulp  is  very 
liable  to  all  those  conditions  and  stages  that  are  to  be  met  witli 
in  delicate  structures  largely  supplied  with  nerves  and  bloodves- 
sels, comprehended  under  the  general  designation  of  inflamma- 
tion, which  we  shall  dwell  upon  in  connection  with  the  subject 
of  the  following  chapter. 

[Tliere  has  come  to  my  knowledge  at  least  one  case  of  threat- 
ened apoplexy,  which  was  aggravated  if  not  induced  by  i)ulp 
cap[iing  and  which  was  averted  by  extraction  of  the  tooth. 
Operatiojis  performed  without  due  regard  to  the  general  health 
of  the  patient,  are  not  infrequently  the  cause  of  serious  disease.] 


PERIODONTITIS.  235 


CHAPTER    X. 

PERIODONTITIS. 

Inflammation  of  tlie  periosteum  of  the  tooth — tlie  periodontal 
or  alveolo-dentaP  membrane — is,  as  has  been  already  pointed 
out,  a  very  common  sequence  to  caries,  and  therefore  a  descrip- 
tion of  its  symptoms,  pathology,  and  treatment  naturally  fol- 
lows that  of  the  latter  disease.  It  occurs  in  both  the  acute  and 
chronic  forms,  sometimes  commencing  in  the  former  and  termi- 
nating in  the  latter,  and  vice  versa.  Although  by  far  most 
frequently  the  result  of  dental  caries,  it  at  times  appears  with 
apparently  perfectly  sound  teeth  ;  it  is  also  a  concomitant  of 
stomatitis,  whether  of  idiopathic,  rheumatic,  syphilitic,  or 
mercurial  or  other  medicinal  origin.  As  a  concomitant  of  den- 
tal caries  its  origin  is  probably  due  to  the  presence  of  septic 
matter  generated  by  a  decomposing  pulp,  which  may  come  into 
direct  contact  with  the  membrane  itself,  or  may,  through  the 
dentine  and  cementum,  so  influence  it;  or  may,  as  some  have 
supposed,  aflect  it  through  the  vessels  which  supply  both  the 
pulp  and  the  alveolo-dental  membrane.  It  is  possible,  when 
occurring  to  a  perfectly  sound  tooth  without  any  conditions 
which  may  account  for  it,  that  it  may  arise  from  embolism  of 
the  nutrient  vessels  of  the  pulp;  when  due  to  rheumatism  or 
syphilis,  it  no  doubt  arises  from  depositions,  the  result  of  those 
alfections  which  have  a  predilection  or  aflinity  for  such  fibrous 
structures.  Cold  or  violence  may  in  this,  as  in  any  other  struc- 
ture, be  tlie  proximate  cause  of  inflammation.  The  symptoms 
of  acute  periodontitis  are  generally  of  the  following  character, 
as  we  have  ourselves  experienced  it,  which  agrees  in  the  main 
with  the  description  given  by  other  writers. 

In  the  first  place,  a  tooth  becomes  the  subject  of  attention  on 

'  The  Latin  term  lias  been  adopted  by  C.  S.  Tomes,  as  it  explains  more  cor- 
rectly the  true  nature  of  this  structure. 


236    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

account  of  peculiar  and  uncomfortable,  rather  than  of  painful, 
sensations.  It  soon  appears  to  be  sliirlitly  elongated,  i.  e.,  ex- 
truded from  its  socket,  and  also  slightly  loosened,  which  is  the 
case,  for,  on  closing  the  mouth,  it  can  be  felt  to  be  pressed  into 
its  socket,  and  on  opening  the  mouth  it  seems  to  part  from  its 
antagonist  with  a  sensation  of  stickiness.  Biting  on  the  tooth 
at  this  stage  appears  to  offer  comfort,  although  it  probably  by 
no  means  improves  the  condition  of  matters.  It  may  happen 
that  recovery  takes  place  at  this,  the  first  stage,  although  the 
disease  more  frequently  runs  on  to  another,  in  which  the  result 
of  pressure  is  anything  but  agreeable;  and  this  tenderness  in- 
creases until  even  the  slightest  attempt  to  close  the  mouth,  and 
even  contact  with  the  tongue,  becomes  intolerable.  Indepen- 
dently of  that  caused  by  pressure,  pain  of  a  constant  character, 
varied  only  by  an  aggravation  at  each  pulsation,  is  experienced, 
which  generally  continues,  it  may  be  for  some  days,  until  a 
swelling  appears  in  the  neighborhood  of  the  tooth,  or  some 
adjacent  part,  when,  as  a  rule,  there  is  considerably  mitigation. 
Subsequently  the  swelling  becomes  more  defined  and  prominent 
at  one  part, — the  pointing  of  an  abscess, — which  bursts  and  evac- 
uates the  matter  it  contains,  when  a  still  greater  mitigation  of 
all  the  unpleasant  symptoms  is  experienced.  It  is  generally 
some  little  time  before  the  swelling  entirely  disappears,  or  the 
discharge  ceases  to  be  secreted :  often  for  years  afterwards  a 
small  fistulous  opening  remains,  through  which  small  quantities 
of  pus,  increased  through  cold,  gastric  disturbance,  etc.,  find 
their  way  to  the  surface. 

Of  all  the  teeth,  the  lateral  incisors  of  the  upper  jaw  appear 
the  most  liable  to  attacks  of  acute  periodontitis.  The  fact  has 
been  pointed  out,  but  the  reason  not  explained.  When  it  at- 
tacks these,  the  upper  lip  usually  becomes  considerably  swollen, 
as  does  also  the  facial  depression  formed  by  the  myrtiform  fossa, 
and  the  tissues  to  the  outer  side  of  the  nasal  i)rocess  of  the  supe- 
rior maxilla ;  the  swelling  often  extending  up  to  the  lower  eyelid, 
with  considerable  ecchymosis  at  this  [lart.  There  may,  on  the 
other  hand,  be  little  or  no  swelling  on  the  anterior  i)ortions  of 
the  jaw,  but  there  may  be  considerable  in  the  palate,  extending 
quite  as  far  as  the  limits  of  the  hard  palate.  No  teeth  are,  we 
believe,  so  likely  to  cause  the  palatal  swellings  as  the  upper 
lateral  incisors,  which  swellings  often   exist  for  a  considerable 


PERIODONTITIS. 


237 


time,  when  the  cause  of  their  existence  has  apparently  been 
removed.  Swellings  in  the  same  positions  may  arise  from  any 
of  the  upper  six  front  teeth,  and  pus  may  evacuate  itself  ante- 
riorly over  the  apices  of  their  roots,  or  in  the  palate,  or  into  the 
nares,  and  more  rarely  ui)on  the  surface  of  the  face.  In  the 
case  of  the  bicuspids  and  molars,  the  matter  generally  points 
over  the  roots  on  the  external  alveolar  wall,  where  the  bone  is 
thinnest;  occasionally  it  appears  on  the  inner  surface  of  the 
cheek  opposite  to  the  tooth,  and  not  far  from  Stenon's  duct; 
it  probably  takes  this  course  when  the  matter  is  formed  above 
the  inner  fibrous  covering  to  the  buccinator  muscle.  From 
these  teeth  also  pus  may  evacuate  in  the  palate,  especially  when 
the  mischief  pertains  chiefly  to  the  palatine  fangs  of  the  molars. 

[Prof.  Garretson  had  an  unusually  interesting  case  of  this 
character,  where  perforation  of  the  salivary  duct  occurred, 
causing  a  persistent  opening  upon  the  external  face  of  the  cheek, 
a  diagnosis  being  thereby  very  much  obscured. 

Somewhat  like  the  above  was  the  case  of  Mr.  R.,  in  whom 
a  diseased  lateral  incisor  excited  inflammation  and  abscess 
opening  into  the  antrum,  and  thence  into  the  nares,  resulting  in 


Fisr.  218. 


Fis;.  219. 


From  cast  of  mouth  showing  a  cystic  tumor. 


The  same  after  treatment. 


a  huge  sack,  dependent  from  the  roof  of  the  mouth.  This  was 
treated  by  making  an  opening  from  the  mouth  through  the  ex- 
ternal alveolar  plate  into  the  tumor,  and  introducing  stimuli, 
principally  tincture  of  iodine.  The  bony  palate  was  absorbed 
at  one  point,  admitting  the  finger  to  press  up  the  mucous  tis- 
sues through  the  jjalatal  process  of  the  superior  maxilla.  In 
time  the  opening  in  the  bone  was  filled  by  a  cartilaginous  ma- 


238    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

terial,  -wliicb  when   last  seen  bad  probably  been  ossified,  as  it 
was  hard  and  resistant. 

It  ma}'  be  added  that  the  first  figure  (Fig.  218)  is  taken  from 
an  impression  made  after  the  size  of  the  cyst  had  been  ranch 
reduced  by  emptying  it  through  the  opening  in  the  alveolar 
plate,  and  the  tissues  were  no  longer  distended  by  their  fluid 
contents. 

Attention  is  called  to  the  dropping  inward  of  the  right  cuspid, 
from  the  loss  of  the  bone  and  the  contraction  of  the  cicatrix  of 
the  palatine  process  of  the  superior  maxilla.] 

In  the  lower  jaw,  such  abscesses,  occurring  from  incisors  and 
cus|:)idati  whilst  generally  opening  near  the  apices  of  their 
fangs  on  the  external  alveolar  surface  0[>posite  to  the  lower  lip, 
occasionally  point  on  the  outer  surface  under  the  chin;  more 
rarely  they  do  so  on  the  inner  surface  of  the  alveolus  about  the 
root  of  the  tongue.  Abscesses  from  the  bicuspids  and  molars 
most  commonly  open  on  the  external  alveolar  surface,  about  the 
apices  of  the  roots,  but  also  very  frequently  on  the  external  sur- 
face, not  far  from  the  angle  of  the  jaw  ;  and  these,  if  permitted 
to  continue,  give  rise  to  an  unsightly  puckered  scar,  not  unfre- 
qnently  resembling  and  mistaken  for  the  result  of  a  strumous 
abscess.  The  abscesses  set  up  by  the  lower  third  molars  are 
the  most  severe  and  formidable  in  their  character  and  results. 
We  have  witnessed,  as  such,  a  mass  of  brawny  tissue  extending 
from  the  angle  of  the  jaw  to  the  clavicle,  the  structures  matted 
together,  and  infiltrated  with  pus  flowing  from  several  orifices, 
all  characteristic  of  well-marked  phlegmonous  erysipelas.  Occa- 
sionally, but  happily  rarely,  such  abscesses  open  into  the 
pharynx  or  oesojihagus ;  and  a  case  of  evacuation  into  the  tra- 
chea, attended  with  a  fatal  result,  has  been  recorded  by  G.  Pol- 
lock. 

The  pathology  of  periodontitis  has  been  variously  described, 
but  we  believe  that  the  following  account  of  its  nature  and  [iro- 
gress,  which  n)ay  difler  in  some  respects  from  the  views  of 
otliers,  will  be  found,  upon  the  whole,  in  accordance  with  the 
conditions  as  they  present  themselves.  Owing  to  the  causes 
already  alluded  to,  viz.,  cold,  violence,  the  extension  of  previous 
inflammation  in  adjacent  parts,  the  presence  of  obnoxious  ma- 
terial in  the  form  of  rheumatic  or  syphilitic  deposits,  but  more 
especially  of  septic  material,  the  alveolo-dental  n)embrane  suf- 


PERIODONTITIS. 


239 


fers  irritation  at  certain  spots.  This  irritation  results  in  those 
changes  which  have  heen  so  industriously  studied  in  the  web 
of  the  frog's  foot,  wing  of  tiie  bat,  mesentery  of  the  frog,  tail  of 
the  fish,  etc.  Tiie  vessels  at  the  irritated  sjiot,  whether  pri- 
marily contracted  or  not,  become  dilated,  whilst  the  blood  which 
they  contain  becomes  retarded  in  its  flow,  with  complete  stagna- 
tion at  certain  points:  without  the  limits  of  the  area  of  irrita- 
tion the  vessels  are  dilated,  and  the  circulation  more  than  nor- 
mally active.  This  probably  constitutes  the  stage  of  congestion 
of  tlie  alveolo-dental  membrane,  which  becomes  enlarged  in 
consequence,  and  this  enlargement  can  only  be  effected  by  an 
elevation  of  the  tooth  in  its  socket :  hence  also  the  apparent 
looseness  of  the  tooth.  Pressure  on  the  tooth  at  tliis  period 
forces  the  blood  from  the  dilated  vessels  of  the  membrane,  and 
hence  no  doubt  the  comfort  experienced  by  this  act.  In  the 
next  stage,  at  the  stagnant  parts,  the  vessels  become  crowded 
and  finally  blocked  up  with  the  red  corpuscles  which  adhere  to 
their  walls,  whilst  the  white  corpuscles,  in  like  manner  adher- 
ent, are  seen  in  increased  quantity:  these  latter  put  forth  pro- 
cesses which  penetrate  the  walls  of  the  vessels,  and,  enlarging 


Fig.  320. 


Diagram  to  Illustrate  the  passage  of  the  white  blood-corpuscles  through  the  walls  of  a  blood- 
vessel, and  their  subsequent  migration  between  the  fibres  of  the  surrounding  connective  tissue. 
The  red  and  white  blood-cells  are  not  represented  in  their  due  proportions,  as  this  would  ob- 
scure the  chief  point  we  desire  to  illustrate. 

on  the  outer  sides  of  the  vessels,  and  diminishing  on  the  inner, 
thus  transport  their  contents  or  substance  through  them  (Fig. 
220):  when  free,  the  cells  travel  towards  the  irritated  spots  by 
aid  of  their  amoeboid  contractility,  the  changes  in  the  surround- 
ing connective  tissue,  by  the  softening  and  fusion  of  its  fibres, 


2i0    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

rendering  their  passage  more  easy.  Besides  the  passage  of  the 
white  blood-cells,  serum,  more  or  less  considerable  in  quantity, 
has  passed  out  of  the  vessels  into  the  surrounding  tissue,  and 
probably  by  its  presence  and  pressure  gives  rise  to  the  pain  ex- 
perienced at  this  stage,  when  biting  on  the  tooth  can  no  longer 
simply  empty  the  vessels  of  their  surplus  quantity  of  blood,  but 
causes  abnormal  pressure  on  the  hyperfesthetic  nerves. 

In  the  next  stage,  we  get  a  rapid  cell-proliferation  at  the 
spots  of  chief  irritation,  accompanied  also  no  doubt  by  a  similar 
proliferation  of  the  cells  of  the  adjacent  connective  tissue,  and 
these  formations,  taking  place  within  hard  and  unyielding  sur- 
roundings, account  for  the  constant  pain,  increased  by  the 
further  pressure  of  each  pulsation  before  alluded  to.  But  the 
ever-present  connective  tissue  of  the  body,  not  excluding  bone 
itself,  shares  in  the  process  of  suppuration,  until  finally  the  ex- 
ternal surroundings  become  involved:  we  discard  the  idea  of  a 
pyogenic  membrane,  which  on  the  one  side  possesses  a  property 
of  secreting  pus,  and  on  the  other  a  property  of  absorbing  adja- 
cent tissues.  When  the  bone  is  lost,  the  pressure  of  the  mass  of 
cells  with  the  products  of  their  fatty  degeneration — pus — readily 
distends  the  softer  tissues  of  the  mucous  membrane,  and  with 
this  swelling  and  lessening  of  pressure  comes  a  general  relief 
from  pain.  A  continuance  of  the  process  causes  a  like  breaking- 
down  towards  the  surface;  in  such  direction  probably  because 
the  tissues  most  remote  from  their  blood-supply  possess  the 
least  power  of  resistance  until  only. the  epithelial  covering  is 
left,  which  speedily  gives  way  and  the  matter  is  evacuated. 
The  amount  of  matter  formed  in  an  alveolar  abscess  varies  con- 
siderably, about  half  a  teacupful  being  sometimes  evacuated  at 
the  first  opening,  whilst,  for  some  days  following,  the  discharge 
may  be  considerable:  after  a  time  it  may  heal  up  by  granula- 
tion, but  its  doing  so  raj>idly,  or  otherwise,  will  much  depend 
upon  the  nature  of  its  first  cause:  thus,  if  it  has  been  due  to 
the  presence  of  septic  matter,  the  result  of  a  necrosed  tooth,  so 
long  as  this  remains  so  long  will  pus  in  smaller  or  greater 
quantities  be  secreted.  When  such  abscesses  open  externally, 
as  in  the  case  of  the  lower  molars  especially,  an  opportunity  is 
afforded  for  seeing  for  how  long  a  time  after  the  opening  of  the 
abscess  pus  continues  to  exude,  drop  l)y  drop,  from  the  fistulous 
orifice,  which  consists  of  a  mass  of  granulations  of  nipple  form, 


PERIODONTITIS.    •  241 

whilst  the  surronnditio;  structures  are  twined  to  tlie  bone  loy 
adhesions  which  have  undergone  contraction,  presenting  a 
most  unsiglitly  spectacle.^ 

The  general  symptoms  are  those  which  are  included  under 
the  term  pyrexia;  such  as  an  elevation  of  the  temperature,  a 
quickened,  full,  and  incompressihle  pulse,  a  dry  tongue,  tliickly 
coated  with  brown  fur,  thirst,  head-ache,  absence  of  appetite, 
nrine  scanty  and  high-colored,  and  bowels  usually  constipated. 

The  treatment  will  of  course  be  local  and  general.  In  the 
early  or  first  stage,  when  the  act  of  biting  upon  the  tooth  gives 
a  sense  of  comfort,  the  application  of  continued  warmth,  which 
is  best  accomplished  by  means  of  popjiy  or  chamomile  decoctions, 
a  little  warmer  than  the  tem[ierature  of  the  mouth,  and  held 
within  it,  will  often  atibrd  relief  and  occasionally  arrest  further 
progress.  Cold,  no  doubt,  might  effect  the  same  result,  and 
probably  more  expeditiously,  but  it  is  almost  im[)0ssil)le  to 
ap[ily  cold  continuously  to  the  mouth,  and  a  frequent  alterna- 
tion of  temiterature  is  worse  than  useless.  Cold,  most  probably, 
by  causing  a  contraction  of  the  vessels  at  the  part  congested,  as 
well  as  a  lessening  of  the  active  vital  changes,  restricts  the  pro- 
cess ;  warmth,  on  the  other  haJid,  has  the  opposite  tendency,  viz., 
to  promote  and  augment  those  changes  and  conditions  which  are 
a  part  of  inflammatory  processes,  especially  of  cell-activity  and 
proliferation  ;  but  then  it  encourages  a  more  healthy  circula- 
tion in  the  stagnant  vessels,  and  thus  lessens  the  congestion  and 
tendency  to  exudation  and  cell -migration.  Cold,  to  be  effect- 
ive, must  be  applied  very  early,  and  continuous!}'  maintained, 
until  a  cure  is  effected.  In  a  small  burn,  such  as  the  dropping 
of  ignited  sealing-wax  u['on  the  finger,  which  ordinarily  pro- 
duces a  blister  and   painful   sore,  if  the  part   be  immediately 

'  A  rare  consequence  of  a  dental  fistula  may  be  a  salivary  fistula.  A  case 
of  this  kind  came  under  our  notice  many  years  ago,  in  the  person  of  a  male 
adult,  and  when  we  were  attached  to  the  Metropolitan  Free  Hospital  The 
dental  fistula  which  arose  from  the  root  of  a  lower  tooth  had  been  in  existence 
for  some  time,  and,  when  the  root  was  removed,  the  opening  remained  patent 
and  the  saliva  continually  flowed  through  it.  A  probe  introduced  through  the 
opening  in  the  cheek  passed  readily  into  the  open  alveolus  of  the  tooth.  By 
freeing  the  surroundings  of  the  opening  from  the  bone  to  which  they  were 
adherent,  and  paring  its  edges,  the  opening  was  readily  closed  by  a  silver  wire 
suture,  and  healed  up  without  trouble. 
It) 


242    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

plnnored  into  cold  water,  intense  relief  is  experienced;  and,  if 
it  be  kept  there  ]ougr  enough,  no  blister  will  appear,  or  other 
usual  consequences  of  such  an  injury.  [The  cold  may  be  ap- 
plied by  the  ether  spray  apparatus,  care  being  taken  not  to 
carry  it  to  the  point  of  [)roducing  a  frost-bite.] 

In  the  second  stage,  where  we  have  reason  to  believe  that 
exudation  is  taking  place,  the  application  of  one  or  two  leeches 
to  the  gum  over  the  external  alveolus,  corresponding  to  the 
apex  of  the  fang  of  the  tooth,  is  often  productive  of  great  relief, 
the  tooth  generally  appearing  to  recede  again  into  its  socket ; 
indeed,  the  same  remedy  may  be  employed  with  benefit,  if  it  be 
considered  worth  the  trouble,  in  the  first  stage.  [Holding  hot 
water  in  the  mouth,  although  it  produces  an  exacerbation  of 
pain  at  first,  will  almost  invariably  be  followed  by  relief  after 
persevering  in  its  use  for  half  an  hour  or  more,  the  result  of 
the  reaction  from  continued  hot  applications.]  The  bleeding 
should  be  encouraged,  after  the  leech  has  ceased  sucking,  with 
warm  water,  within  moderate  limits,  and  when  it  has  quite 
ceased,  the  poppy  or  chamomile  fomentation  may  be  continuously 
used.  It  is  never  well  to  apply  the  fomentation  or  poultices  to 
the  external  surface,  for,  although  they  undoubtedly  afford 
relief,  they  render  the  tendency  greater  for  an  abscess  to  open 
on  such  surface.  In  the  second  stage,  if  it  has  not  been  seen 
to  in  the  first,  the  bowels  should  be  well  opened;  the  whole 
trouble  having  probably  arisen  as  much  from  a  systemic  as  from 
a  local  cause.  We  often  remove  teeth  in  which  there  has  never 
been  other  than  the  inflammation  which  would  have  been  caused 
by  the  simplest  irritants,  yet  not  only  the  pulp-cavity  and  den- 
tine are  in  a  highly  offensive  condition,  but  also  the  alveolo- 
dental  membrane ;  the  latter  a  mass  of  apparently  noxious  sep- 
tic material,  exuding  fluids  of  the  same  character.  We  can 
therefore  only  account  for  those  severer  forms  of  erysipelatous 
character  as  being  due  to  a  peculiar  state  of  the  system,  or  to 
an  altered  condition  in  the  surrounding  vessels.  [Extraction 
is  now  only  resorted  to  in  rare  cases,  and  should  not  be  per- 
formed duriiig  a  high  state  of  inflammation,  as  it  is  likely  to 
add  greatly  to  the  irritation  already  existing.]  The  former  is 
probably  the  more  correct  view,  and  for  the  reason  that  we  find 
these  attacks  generally  associated  with  some  debilitating  con- 
dition, such   as   probably  conduces,  as  Simon  points  out,  to  an 


PERIODONTITIS.  243 

accumulation  of  those  products  of  disintegrated  tissues  in  the 
blood  which  in  liealth  are  eliminated  from  it  by  imiiortant  ex- 
creting organs  of  tlie  body.     A   sudden  chill   appears  a  very 
common  forerunner  of  these  attacks,  and  nothing  is  more  likely 
to  affect  the  excreting  organs  ;  great  mental  strain  and  overwork 
is  another,  and  probably  also  by  their  indirect  effects  on  the 
same  organs.     [A  chill  is  a  very  valuable  diagnostic  sign  of  the 
formation  of  pus  in  an^'  part  of  the  body,  and   it  is  not  excep- 
tional when  pus  forms  at  the  root  of  a  tooth.     It  may  be  indefi- 
nite, as  a  mere  crawl  or  cree[»ing  of  a  cool  sensation,  generally 
down  the  back,  or  it  may  be  so  pronounced  as  to  be  quite  evident 
to  others  than  the  patient.]     Aperients  and  diuretics  are  there- 
fore certainly  indicated  in  the  early  stages  of  acute  periodon- 
titis.   When  these  have  exhibited  their  desired  effects,  we  may 
with  much  advantage  prescribe  tonics,  the  best  of  which,  in  our 
exi)erience,  are  bark  and  sulphuric  acid.^     Nothing  appears  so 
readily  to  remove  the  fur  from  the  tongue  as  this  does ;  and, 
though  it  may  be  said  to  favor  suppuration  on  the  one  hand,  it 
undoubtedly  strengthens  the  system  to  bear  it  on  the  other,  and 
may  even  enable  the  sj^stem  to  dispose  of  the  products  of  cell- 
formation  without    permitting   them   to  degenerate  into  pus. 
We  witness  this  in   certain   rare  cases  where  the   disease   is 
arrested  in  the  second  stage,  the  products  of  inflammation  be- 
coming organized  and  remaining  as  a  swelling,  which  after  some 
time  entirely  disappears.     [These  cases  are  frequently  annoying 
from   the  persistence  of  the  swelling  ;  they  are  at  times  bene- 
fited by  deep  lancing  and   treating  the  interior  with  iodine. 
Constant  pressure,  by  a  pad  of  cotton  wool  or  carbolized  flax  or 
oakum  laid  between  the  gum  and  cheek,  will  reduce  them  gene- 
rally with  the  least  trouhle  and  pain.]     In  the  later  stages, 
when  suppuration  is  inevitable,  the  patient  should  be  well  sup- 
ported with  soft  nutritious  diet,  and,  if  necessary,  a  liberal 
amount  of  stimulant.     During  tl>e  jteriod  of  the  acutest  pain, 
when  it  is  more  than  probable  that  matter  has  formed,  it  is  a 
question  whether  much  relief  might  not  be  afforded  by  treating 

'  U. — Acidi  sulpliurici  dil.  3ij- 
Decoct,  ciachonse,  §viij. 
M.  ft.  liaust. 
An  eighth  part  twice  or  thrice  in  the  day 


244       Manual  of  dExNtal  surgery  and  pathology. 

as  for  abscess  in  hone,  i.  e.,  by  trepbinino; ;  an  anaesthetic  might 
be  employed  during  the  process.  Could  we  always  insure  hit- 
ting upon  the  exact  spot,  it  might  be  safely  recommended  ;  but, 
as  these  abscesses  often  form  at  no  inconsiderable  distance  from 
the  tooth,  failure  would  probably  add  much  to  the  patient's 
sufterings;  the  lower  jaw  would  probabl}^  be  safer  so  to  operate 
on  than  the  upper.  [An  ordinary  spear  point  drill  (No.  163, 
Fig.  115)  in  the  engine  will  penetrate  in  a  moment  and  give 
relief  in  a  large  percentage  of  cases  within  half  an  hour.] 

Bell,  in  treating  upon  alveolar  abscess,  makes  a  distinction 
between  those  which  occur  in  the  immediate  neighborhood  of 
a  tooth  and  those  which  occur  at  some  distance;  believing, 
however,  the  cause  of  both  to  be  one  and  the  same  we  see  no 
object  in  drawing  such  distinction. 

Should  the  disease  occur  in  teeth  apparently  sound,  and  with- 
out any  previous  debilitating  or  otherwise  predisposing  con- 
ditio!is,  we  may  suspect,  in  those  who  are  the  subjects  of  rheu- 
matism, that  it  is  of  such  origin,  and  we  have  found  it  yield 
readily  to  an  alkaline  treatment.  In  those  who  are  the  subjects 
of  syphilis,  iodide  of  potassium  is  doubtless  the  best  remedy  ; 
and,  should  it  occur  as  the  result  of  mercurial  treatment,  chlo- 
rate of  potash,  both  internally  and  as  a  lotion,  appears  to  give 
the  most  speedy  relief. 

In  describing  the  treatment  of  periodontitis  we  have  presumed 
that  the  tooth  or  teeth  affected  have  been  sound,  or  at  all  events 
serviceable  ones ;  should  it  be  otherwise,  and  not  the  result  of 
extended  inllammation,or  occurring  from  the  causes  eimmerated 
in  the  foregoing  paragraph,  we  may  cut  the  matter  short  by  ex- 
traction. [Since  the  introduction  of  Dr.  Richmond's  gold  and 
the  Gates-Bonwill  porcelain  crowns,  the  facility  with  which 
roots  are  used  for  supporting  their  share  of  masticatory  pressure, 
adds  to  the  duty  of  persistent  efforts  to  save  the  roots  and  delay 
extraction.]  In  former  days  it  was  not  the  custom  to  remove 
teeth  the  surroundings  of  which  were  greatly  inflamed  ;  Ave  know 
of  no  objection  to  so  doing  other  than  the  i)ain  occurring  at  the 
time,  and  generally  for  some  hours  after.  A  surgeon  would 
surely  never  refuse  to  withdraw  a  splinter  from  the  flesh,  how- 
ever severely  inflamed,  provided  he  could  readily  grasp  the  same ; 
in  each  case  the  removal  of  the  foreign  body,  the  cause  of  the 
mischief,  would,  if  practicable,  be  tlie  right  course  ;  at  the  same 


PERIODONTITIS.  245 

time  no  positive  rule  on  the  subject  can  be  laid  down  ;  there  are, 
for  instance,  those  forn)s  of"  inflammation  liavini;  the  tendency 
to  ulceration  of  surface,  in  which  an  open  wound  would  be  a 
most  undesirable  condition.  With  regard  to  opening  the  abscess 
by  the  knife,  or  allowing  it  to  open  spontaneously,  much  will 
depend  upon  its  position  and  condition;  if  it  ap[)ear  to  be  point- 
ing in  a  suitable  position  and  without  hindrance,  it  may  be  left 
alone,  but  we  may  by  a  somewhat  bold  incision  prevent  its 
opening  on  the  external  surface  ;  where  it  appears  bagging,  and 
discharging  at  one  or  more  small  openings,  we  may  with  advan- 
tage make  a  free  incision  at  the  most  dependent  part.  [When 
the  tissue  overh'ing  the  pus  is  over  one-eighth  of  an  inch  thick 
lancing  may  be  delayed  without  much  prolongation  of  the  pain 
until  the  pus  finds  its  way  nearer  the  surface ;  otherwise  a  tent, 
saturated  with  carbolic  acid  or  iodine  to  keep  open  the  fistula, 
may  be  necessary,  but  when  used  it  often  adds  to  the  smarting 
pain.] 

Chronic  periodontitis  is  not  unfrequently  the  condition  left 
after  the  acute  form  has  passed  oflf,  whilst,  on  the  other  hand, 
as  before  noticed,  the  chronic  may  suddenly  take  on  the  acute 
form.  It  may  and  generally  does  occur  to  a  greater  or  lesser 
extent  with  teeth  the  vitality  of  which  has  been  lost  through 
violence,  or  destroyed  by  the  employment  of  escharotics  in  the 
process  of  filling,  especially  where  the  fang-cavities  have  not 
been  carefully  cleansed  and  filled,  as  before  described  ;  also  with 
teeth  that  are  much  injured  by  caries  wnth  discharging  pulps. 
It  is,  we  believe,  a  fact  that  such  teeth  become  much  freer  from 
chronic  periodontitis  after  the  whole  of  their  pulps  have  sloughed 
away,  and  the  place  of  their  former  occupation  is  found  sweet 
and  inoffensive.  A  tooth  that  has  been  long  affected  with  chro- 
nic periodontitis  is  generally  much  discolored,  which  gives  it 
the  appearance  of  having  been  filled  with  a  dark  amalgam;  it  is 
usually  more  or  less  coated  with  salivary  calculus,  as  are  also,  not 
only  its  immediate  neighbors,  but  the  corresponding  teeth  of  the 
opposingjaw.  If  pressed  upon  laterally  it  is  seen  to  move  slightly 
in  its  socket,  and  when  tapped  gives  more  or  less  pain,  and  yields 
a  duller  and  less  clear  sound  than  in  the  case  of  a  healthy  tooth. 
The  mucous  membrane  covering  that  portion  of  the  alveolar  pro- 
cess, on  the  external  surface  especially,  which  corresponds  to  the 
situation  of  the  apices  of  its  root  or  roots,  will  be  seen  to  be 


246         MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

cono^ested  and  of  a  deep  purple  color,  whilst  in  the  same  region 
will  occasionally  he  seen  a  small  pustule,  which  at  times  enlarges 
and  discharges  itself:  in  the  latter  case  the  tooth  is  generally  less 
sensitive  to  pressure,  and  ^vill  often  hear  hiting  on.  [The  line 
of  demarcation  hetween  the  deep  color  of  the  gum  under  the 
lip  and  the  light  ])ink  color  of  that  around  the  teeth  has  been 
called  the  health  line.  In  proportion  as  it  is  distinct  and  clear 
it  is  a  sio;n  of  health  of  the  teeth-roots  and  of  freedom  from  in- 
flammation ;  as  this  line  falls  toward  the  free  margin  of  the 
gum,  or  becomes  indistinct,  the  condition  of  disease  is  more  pro- 
nounced.] The  discharge  has  been  considered  by  some  to  he  the 
■fluid  generated  by  the  pulp,  w^hich,  especially  in  the  case  of 
tilled  teeth, thus  makes  its  way  to  the  surface ;  an  error  palpable 
from  the  fact  that  the  tw^o  fluids  have  hardly  any  similarity, 
the  former  being  ordinary  inotiensive  pus,  but  which,  however, 
may  arise  in  consequence  of  the  presence  of  the  latter. 

If  we  remove  a  tooth,  the  subject  of  long-existing  chronic  peri- 
odontitis, we  shall  generally  find  that  it  will  require  less  force 
than  a  healthy  one.  It  mostly  brings  with  it  a  considerable 
portion  of  its  alveolo-dental  membrane,  wdiich  w^e  find  consider- 
ably hypertrophied,  of  a  dark-red  color,  and  emitting  a  most  ott'en- 
sive  odor.  The  apices  of  the  fangs  are  generally  bared  of 
membrane.  In  some  cases  the  tooth  comes  away  free  from  any 
of  the  membrane,  moist,  and  glistening  with  purulent  fluid  ;  this 
is  generally  in  the  severer  cases.  If  we  examine  the  hypertro- 
phied alveolo-dental  membrane,  w^e  find  that  it  sei)arates  much 
more  readily  from  the  root,  especially  near  the  apex,  than  when 
healthy,  being  firmer  as  we  approach  the  neck  of  the  tooth,  where 
it  is  less  attected.  We  have  accounted  for  the  separation  of  the 
membrane  at  the  apex  of  the  fang  as  due  to  the  large  amount 
of  cementum  there,  w^hich,  no  doubt,  is  in  these  cases  necrosed. 
The  membrane  is  found  liighly  congested  and  infiltrated  with 
lymph  and  serum,  and  at  the  portion  attached  to  the  apex  of  the 
fang  there  is  often  a  small  amount  of  pus,  and,  as  its  form  when 
folded  together  somewhat  resembles  a  sac,  it  has  often  been  re- 
garded as  the  sac  of  an  abscess.  Small  abscesses  situated  in  the 
thickened  alveolo-dental  membrane,  as  well  as  small  cysts,  do 
occasionally  come  away  entire  with  the  tooth.  Under  the  micro- 
scope the  fibrous  tissue  of  the  meml)rane  appears  less  compact 
and  discernible  than  in  health;  we  perceive  amongst  its  meshes 


PERIODONTITIS. 


247 


Ficr.  221. 


abundant  cells  and  nuclei ;  many  of  the  cells  are  nucleated  and 
oat-sha{)ed,  elongated  at  their  extremities  to  form  fibres;  and 
some  of  the  cells  appear  in  an  active  state  of  proliferation,  whilst 
others  appear  to  be  undergoing  fatty  degeneration. 

The  treatment  of  chronic  periodontitis  will  much  depend 
upon  the  condition  of  the  tooth  affected  ;  if  its  origin  be  that  of 
violence,  and  in  a  sound  tooth,  a 
leech  may  be  applied,  followed 
by  fomentation  ;  or,  when  tiie  ^\ 
disease  is  very  slight,  and  has 
occurred  from  time  to  time,  a 
small  piece  of  toasted  fig,  or  a 
little  warm  bread  and  milk,  may 
be  placed  in  the  sulcus  formed 
by  the  gum  and  cheek  before 
the  patient  retires  to  rest. 
[There  has  been  so  much  objec- 
tion to  the  effect  of  the  fig  or 
raisin  upon  th.e  adjoining  teeth 
that  they  may  be  said  to  be 
almost  if  not  entirely  substitu . 
ted  by  hot  water,  cotton,  or  tow 
as  recommended  (pp.  242,  243.)] 
In  like  manner  we  may  treat  a 
tooth  wdiich  has  been  filled,  and 
which  at  times  gives  evidence 
of  periodontal  irritation  ;  but 
in  such  cases  counter-irritants 
appear  more  effectual,  and  we 
would  recommend  what  we 
have  suggested  and  found  very 
serviceable,  viz.,  a  saturated 
solution  of  chloride  of  ammo- 
nium,^ which  is  especially  ap- 
plicable in  cases  where  pain 
comes  on  in  a  tooth  after  entering  a  hot  room,  or  when  the  in- 


Aa  alveolar-abscess  syriage  (Farrar's),  for 
injectintr  stimulating  and  antiseptic  fluids 
til  rough  the  fangs  of  teeth,  for  the  treatment 
of  alveolar-abscess  and  chronic  periodontitis. 


'  ^^. — AmmonifB  bj'droclil.  3iij. 
Aquse,  SJ.— M. 
To  be  applied  to  the  gum  with  the  finger  when  pain  comes  on. 


248         MANUAL    OF    DENTAL    SDRGERY    AND    PATHOLOGY. 

dividual  is  over-fatigued.  If  in  eitlier  condition  we  have  reason 
to  suppose  tliut  it  de[>ends  upon  the  presence  of  a  diseased  or 
devitalized  pulp,  or  an}^  portion  of  it,  in  the  one  case,  viz.,  that 
of  a  sound  tooth,  an  opening  should  be  drilled  through  the 
crown  into  the  pulp-cavity  ;  in  the  other,  the  stopping  should 
be  removed,  and  all  the  diseased  substance  carefully  cleared  out. 
The  pulp-cavity  should  be  dressed  with  antiseptic  substances 
until  there  is  reason  to  believe  that  the  dentine  is  free  from 
decomposed  material  before  the  fangs  are  filled  and  the  cavity 
again  sealed  up.  When  it  occurs  in  a  tooth  that  is  carious  and 
has  not  been  filled,  esi^ecially  one  situated  near  to  the  front  of 
the  mouth,  in  which  the  mischief  has  existed  for  some  time, 
besides  clearing  away  all  the  decomi)Osed  pulp-substance,  it  may 
be  well  to  perforate  the  fang,  so  as  to  enlarge  the  foramen  at  its 
apex,  and  also  to  drill  a  hole  through  the  external  wall  of  the 
alveolus  to  meet  this.  That  we  have  accomplished  tliis,  will  be 
evidenced  by  syringing  through  the  fang  and  seeing  the  fluid 
exude  at  the  orifice  in  the  gum,  which  should  be  of  moderate 
size,  and  kept  open  by  a  tent.  The  treatment  will  then  consist 
in  thus  syringing  daily,  oftener  if  possible,  with  some  strong 
antiseptic  fluid, — a  solution  of  iodine  and  creasote  is  probably 
the  best ;  the  tent  should  likewise  be  dipped  in  the  same.  Where 
a  small  gumboil  exists,  it  will  be  only  necessary  to  see  that  tiie 
passages  are  patent.  The  rationale  of  this  treatment  is  the 
attempt  to  correct  the  impurity  of  the  necrosed  dentine  and  the 
cementum  about  the  apex  of  the  root  of  the  tooth.  When  no 
gum-boil  has  existed,  the  simple  removal  of  the  contents  of  the 
pulp-cavity,  and  the  application  of  arsenious  acid,  about  -^^  of  a 
grain,  to  the  contents  of  the  fang-cavity,  covering  with  zinc 
oxychloride,  has,  under  our  hands,  afforded  very  satisfactory 
results,  and  has  the  merit  of  saving  a  long,  tedious,  and  dis- 
agreeable process.  The  treatment  is  on  the  same  principle  as 
that  described  above,  viz.,  a  correction  of  an  existing  septic 
condition.  As  a  final  resort,  extraction  and  replantation,  to  be 
described  hereafter,  may  be  en)i)loyed.  If  the  tooth  attacked 
be  80  imperfect  that  it  would  be  of  little  or  no  value  if  retained, 
we  may  then  speedily  effect  the  cure  by  its  removal ;  and  how 
this  operation  should  l>e  i>est  performed  will  shortly  occupy  our 
attention  in  a  subsequent  chapter. 


PERIODONTITIS.  249 

[Arsenic  cannot  safely  be  applied  if  there  be  inflammation 
and  pain  already  existing,  as  it  is  a  searching,  powerful,  and 
dangerous  irritant,  which  may  so  increase  the  pain  as  to  make 
it  excruciating.  It  is  better  to  apply  first  for  a  day  the  simple 
morphia  paste,  so  as  to  relieve  the  pain  and  quiet  the  inflamma- 
tory action.] 


250         MANUAL   OF    PEMTAL   STEGEET    ASP    PATHOLOGY. 


CHAPTER    XI. 

^'ECROSIS.     ABSOEPTIOK  OF  PEE.MAXEXT  TEETH. 
EXOSTOSIS. 

Xeceosis. — Of  this  we  have  already  epokec  on  sereral  occa- 
sions, but  more  particDlarl}'  in  the  chapter  treating  upon  inju- 
ries to  the  teeth.  Though  it  is,  no  doubt,  in  sound  teeth  by  far 
most  frequently  the  result  of  an  accident,  yet  we  sometimes  find 
teeth  losing  their  vitalitj'  without  any  apparent  cause,  those 
most  liable  being  the  front  teeth,  and  in  the  upper  jaw,  the 
lateral  incisors  especially.  When  arising  spontaneously,  it  not 
improbably  results  from  embolism  of  the  nutrient  artery  sup- 
plying the  pulp,  which  structure  undergoing  change  allows  the 
coloring  matter  of  the  blood  to  stain  the  dentine  or  the  contents 
of  the  dentinal  tubuli,  giving  to  the  tooth  a  fawn  color,  which 
as  time  progresses  changes  to  a  darker  hue.  The  vitality  of  the 
dentine  is  lost,  but  that  of  the  cementum  may  be  retained,  and 
the  tooth  then  remains  serviceable  though  unsightly.  It  is 
rare,  however,  for  the  cementum  not  to  suffer  to  some  extent, 
and,  in  consequence,  the  alveolo-dental  membrane.  As  we  have 
before  pointed  out,  we  may  have  a  living  pulp  with  more  or 
less  necrosis  of  the  cementum ;  this  latter  most  frequently 
occurs  in  cases  of  absorption  of  the  alveoli.  "We  have  met  with 
a  ease  in  which  the  irritation,  caused  by  a  patch  of  necrosed 
cementum  on  the  anterior  surface  of  a  third  lower  molar,  gave 
rise  to  so  much  pain  that  the  tooth  had  to  be  removed;  when 
split  oi»en,  the  pulp  appeared  perfectly  healthy. 

"With  regard  to  treatment  we  may,  in  the  first  class  of  cases, 
drill  into  the  pulp  cavit}-, — if  a  front  tooth,  through  the  pos- 
terior surface  of  its  crown, — and  clear  out  the  whole  of  its  con- 
tents: this  will  lessen  the  chances  of  the  cementum  snffering, 
and,  if  dc»ne  early,  also  probably  lessen  the  discoloration  ;  indeed, 
we  may  attempt  to  bleach  the  tooth,  oxalic  acid  having  been 
found  the  most  effective  agent,  and  finally  fill  up  the  pulp- 


NECROSIS.  251 

cavity  and  hole  in  the  crown.  In  the  second  class  of  cases, 
where  the  ceraentura  only  is  affected,  little,  likely  to  be  of 
benefit,  can  be  suggested.  Could  we  accurately  diagnose  that 
only  a  small  portion  of  cementum  had  suffered,  and  at  a  givea 
8{>ot,  we  might  open  down  upon  it,  and  excise  it,  or  subject  it 
for  a  time  to  the  action  of  creasote  and  iodine. 

[Bleaching  teeth — To  be  successful  in  bleaching  teeth  it  is  im- 
portant to  remember  that  the  stain  may  be  due  to  various 
chemical  agents,  and  that  each  group  will  require  a  different 
bleaching  material.  Thus  the  stain  from  fruits  and  vegetable 
matter  generally  has  hydrogen  for  its  base,  and  therefore  chlo- 
rine, from  the  affinity  between  them,  is  the  proper  applicatiou  to 
make.  For  this  purpose  nothing  will  answer  better  than  fresh 
chloride  of  lime,  which  may  be  purchased  in  small  air-tight 
packages,  and  applied  as  a  putty  or  like  a  temporary  filling. 
Labarraque's  solution  is  also  very  good,  but  a  trifle  more  expen- 
sive. In  the  use  of  this  and  other  chemicals  for  bleaching,  the 
rubber  dam  should  first  be  applied  to  save  the  unaffected  teotb 
and  the  mucous  membrane  of  the  mouth  and  lungs  from  irrita- 
tion by  the  fluids  or  gases. 

For  the  liquidation  of  blood  clots,  ammonia  water  is  valuable. 
AVhere  a  tooth  is  discolored  from  this  cause  it  should  first  be 
washed  out  thoroughly ;  then  a  crystal  of  oxalic  acid  dissolved  bj 
a  drop  of  water  in  the  tooth,  to  remove  the  iron  or  ink  stain, 
carefully  washing  again,  and  as  a  precaution  neutralizing  any 
remaining  acid  by  alkalies, as  ammonia,  etc. 

Nitric  acid  will  dissolve  out  amalgam  residue,  but  it  must  be 
used  with  caution,  by  dipping  in  it  the  extreme  tip  of  a  small 
pointed  stick  and  touching  it  for  a  few  moments  to  the  discolor- 
ation ;  then  plentiful  syringing  with  water,  taking  care  to  finish 
by  applying  ammonia  water  to  neutralize  any  remaining  acid. 

The  deadly  poison,  cyanide  of  potassium,  may  be  used  as  a 
solvent  for  the  metallic  dyes,  applied  like  oxalic  acid  only  with 
exceeding  caution. 

All  bleaching  to  be  permanent  will,  however,  depend  upon  a 
thorough  removal  of  the  discoloration,  even  if  considerable  tooth 
substance  has  to  be  taken  with  it,  and  if  leakage  is  liable  to 
occur  again  through  the  apex  of  the  root  or  pulp  canal,  the 
latter  is  best  filled  solidly  with  gold — indeed,  it  is  generally  the 
first  step  in  the  treatment  after  the  recovery  of  the  apical  tis- 


252 


MANUAL  OF  DENTAL  SURGBRY  AND  PATHOLOGY. 


sues,  and  essential  to  prevent  irritation  of  the  apical  pericemen- 
tal tissue,  !)}•  the  l^leachini^  material ;  even  the  fumes  are  ordi- 
narily sufficient  to  cause  trouble.  This  preparatory  canal 
fillint;;  should  not  come  down  quite  to  the  point  at  which  the 
dentinal  tubuli  leave  the  canal  for  the  neck  of  the  tooth,  as 
it  is  through  these  that  the  bleaching  is  accomplished  in  the 
dentine  under  the  enamel. 

Fisr.  223. 


Hot  air-syringe.  A,  Entrance  valve  ;  B,  Valve  to  prevent  the  heated  air  from  passing  back  into 

the  rubber  bulb. 


Finally,  complete  drying  by  the  hot  air  syringe  will  be  fol- 
lowed in  most  cases  by  the  greatest  improvement.  The  filling 
may  be  made  to  subserve  a  good  purpose  in  those  cases  where 
the  tooth  still  remains  slightly  darker,  as  by  inserting  oxychlo- 
ride  of  zinc  we  may  obtain  the  advantage  gained  from  a  white 
reflecting  surface  under  the  dentine.] 

Absorption  of  permanent  teeth. — This  condition,  which  we  re- 
gard as  normal  and  necessary  in  the  case  of  the  temporary  teeth, 
is  a  pathological  one  when  occurring  in  the  case  of  the  perma- 
nent teeth,  although  at  times  the  two  processes  are  not  very 
dissimilar:  thus  it  is  not  very  uncommon  to  find  the  fang  of  a 
lateral  incisor  more  or  less  absorbed  where  an  uneru[)ted  or  par- 
tially erupted  cuspidatus  has  approximated  abnormally  to  it ; 
or,  again,  a  second  molar  of  the  lower  jaw  may  in  like  manner 
be  found  to  have  undergone  absorption  at  the  point  impinged 
upon  by  the  crown  of  an  erupting  wisdom  tooth  (E'ig.  223). 
[This  is  a  not  infref4uent  predisposing  cause  of  decay,  and 
mouths  will  be  found  otherwise  almost  free  from  the  disease, 
except  at  the  points  where  lodgment  of  food  has  caused  almost 
irreparable  injury.]  Teeth  which  have  suffered  from  violence 
often  undergo  more  or  less  absor[>tion  at  their  fangs;  a  tooth 
subjected  to  immediate  torsion,  as  we  have  narrated,  was  found 
to  have  lost  nearly  the  whole  of  its  fang.     Transplanted  dried 


NECROSIS, 


253 


teeth  almost  invariably  suft'er  in  the  same  manner.  But  the 
condition  of  ahsorjition  in  the  permanent  teeth  is  most  com- 
monly witnessed  wliere  for  a  loni;:  time  a  more  or  less  congested 
or  inflamed  periosteum  has  existed.  In  attempting  to  account 
for  the  various  phenomena  met  with  in  ahsorption  of  the  teeth, 
the  dijfficulties  have,  we  think,  been  augmented  by  our  looking 
for  special  organs  capable  of  eftecting  the  process.     Altered  con- 


Fisr.  223. 


Fi?.  224. 


Unerupted  wisdom  tooth,  which 
by  pressure  has  caused  absorption 
of  the  approximal  surface  of  a  sec- 
ond molar. 


Absorption  of  the  roots  of  three  permanent  incisor  teeth. 
(Copied  from  specimens  in  the  author's  possession). 


ditions  in  their  surroundings  have  no  doubt  the  greatest  influ- 
ence in  efl:ecting  either  their  hypertrophy  or  their  atrophy  ;  an 
undue  determination  of  blood  may  stimulate  the  osteoblastic 
layer  of  the  ceraental  portion  of  the  alveolo-dental  membrane, 
and  so  produce  hypertro])hy  of  the  cementum.  On  the  other 
hand,  stimulation  of  the  osteohlastic  layer  of  the  alveolar  por- 
tion of  the  same  membrane  may  induce  growth  of  the  alveolus 
inwards.  The  result  of  this  latter  may  be  pressure  upon  the 
osteohlastic  layer  of  the  cemental  portion  of  the  membrane,  and 
in  consequence  induce  the  osteoblasts  to  take  on  an  ahsorptive 
action,  in  fact  to  become  osteoclasts,  and  effect  more  or  less  the 
destruction  of  the  fangs  of  the  teeth.  The  absorption  of  bone 
brought  about  by  the  pressure  of  an  aneurism  is  no  doubt  ef- 
fected by  the  same  agency. 

The  condition  of  absorption  may  attack  teeth  singly,  or  seve- 
ral at  a  time,  and  we  have  seen  a  case  where  the  whole  of  the 
upper  six  front  teeth  were  thus  lost,  one  after  another.  In  the 
way  of  treatment  we  fear  we  can  suggest  but  little  that  will 
prove  of  beneflt.  To  endeavor  to  preserve  the  raucous  mem- 
brane of  the  gums  as  free  from  hyper?emia  as  possible,  is  of 
course  indicated,  but  when  the  teeth  become  loose  and  trouble- 
some, we  can  only  suggest   their  removal  and  sul  stitution  by 


254 


MANUAL   OP    DENTAL   SURaERY    AND    PATHOLOGY. 


artificial  ones.  In  cases  in  which  it  results  from  the  pressure 
of  an  iinerupted  tooth,  and  is  usually  accompanied  by  consid- 
erable pain,  the  same  treatment  is  the  only  one  which  presents 
itself. 

Exostosis. — This  is  the  reverse  of  the  condition  which  we 
have  last  described,  and  consists  in  an  augmentation  to  the 
cemental  layer  covering  the  fangs.  When  it  is  pretty  evenly 
distributed  over  the  surface  of  the  fang  or  fangs  we  may  with 
advantage  adopt  the  term  hyperostosis,  and  confine  the  former 
term  to  cases  where  the  deposit  is  circumscribed  and  nodulated. 
It  occurs  most  frequently  in  the  case  of  teeth  which  have  suf- 
fered by  wear  upon  their  masticating  surfaces,  and  this,  no 
doubt,  has  determined  an  irritation,  with  increased  flow  of  blood, 
and  consequent  augmented  supply  of  nutrition  to  the  region  of 
their  roots.  By  this  means  an  abnormal  energy  is  given  to  the 
odontoblastic  layer  of  the  cementum,  causing  an  increase  in  the 
latter,  sometimes  to  a  very  considerable  extent.  Such  struc- 
ture, when  examined,  will  be  found  to  approach  ordinary  bone 
in  its  character ;  thus  we  often  have  Haversian  canals,  and 
irregularly  formed  Haversian  systems,  which  are  rare  but  not 
impossible  to  meet  wiih  in  ordinary  cementum.  The  conditions 
of  dental  hyperostosis  have  been  examined  and  ably  described 
by  Hubert  Shelley,  but  we  think  that  his  descriptions  apply 
rather  to  cases  where   more  inflammatory  action  accompanies 


Fig.  235. 


Cases  of  hyperostosis  and  exostosis  in  the  fanps  of  teeth.    (Copied  from  specimens 
in  tlie  author's  possession.) 

the  process  than  to  the  more  gradual  and  more  characteristic 
ones.  In  most  cases,  but  not  in  all,  —  nor  even  in  marked 
ones, — there  is  more  or  less  of  pain  attendant  on  tlie  process, 
attributable,  no  doubt,  to  a  want  of  due  correspondence  between 
the  eidargement  of  the  cementum  and  a  complementary  en- 
largement of  the  alveolus,  with  consequent  pressure  upon  the 


EXOSTOSIS.  255 

nerves  of  the  intermediate  tissue.  If  this  be  the  right  explana- 
tion, it  is  not  difficult  to  account  for  the  process  occurring  at 
times  without  pain,  at  other  times  with  moderate  pain  of  even 
and  persistent  character,  and  again  at  times  with  pain  of  an 
excruciating  character.  The  pain  also  is  not  unfrequentl}-  re- 
ferred to  other  parts  than  the  ones  aitected,  occurring  in  the 
head  and  face,  about  the  ear,  indeed,  at  any  of  the  terminal 
branches  of  the  fifth  pair.  Many  supposed  cases  of  neuralgia 
have  their  origin  in  this  cause,  which  is  often,  before  the  re- 
moval of  the  teeth  so  afiected,  very  obscure.  Such  teeth  may  be 
free  from  tenderness  when  percussed  or  bitten  on.  The  margin 
of  the  gum  around  teeth  which  are  the  subjects  of  hyperostosis 
may  present,  but  not  invariably,  a  line  of  congestion  said  to  be 
characteristic  of  this  condition.  In  such  cases  the  electric 
mouth-illuminator  of  Hart  might  prove  valuable,  as  the  roots 
of  teeth  are  distinctly  seen  when  the  apparatus  is  placed  within 
the  mouth. 

As  may  well  be  expected,  the  removal  of  such  teeth  is  often 
attended  with  much  difficulty,  especially  where  the  deposition 
has  been  greatest  towards  the  extremity  of  the  root  or  roots. 
We  shall  infer  this  to  be  the  condition,  when,  after  separating 
a  tooth  from  its  membranous  attachments,  we  find  it  loose,  yet 
having  a  strong  impediment  to  its  removal  :  a  curved  fang 
would  likewise  offer  the  same  resistance.  AVe  must  here  very 
cautiously  and  patiently  continue  the  loosening  moven)ents, 
until  we  have  so  dilated  the  uj'per  portion  of  the  alveolus  as  to 
permit  the  enlarged  or  twisted  root  to  come  out.  From  this 
cause,  lower  bicuspid  teeth  or  roots  are  not  uncommonly  very 
difficult  to  remove,  even  when  not  so  considerably  enlarged  at 
their  radical  apices.  Our  museums  show  to  what  an  extent  the 
cementum  may  increase  in  rare  cases,  at  times  even  uniting 
together  the  roots  of  contiguous  teeth,  but  cases  of  a  moderate 
amount  of  increase  are  extremely  common. 

With  regard  to  treatment,  we  again  fear  that  little  more  can 
be  oftered  than  the  radical  one  of  extraction;  but,  before  we 
resort  to  this  extremitj',  iodide  of  potassium,  in  somewhat  large 
doses,  should  have  a  trial. 

[It  is  always  of  service  to  place  such  teeth  in  a  normal  con- 
dition, by  having  them  meet  their  antagonists  properly ;  this 
may  require  modification  of  their  shape  by  filing,  or  grinding 


256    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

with  corundum  wheels  on  the  dental  engine;  sometimes  cap- 
ping the  adjoining  ones  to  relieve  undue  pressure,  and  at  others, 
where  no  antagonizing  tooth  is  present,  inserting  an  artificial 
one.  Counter-irritation,  as  a  blister  over  the  root,  by  painting  the 
gum  with  the  saturated  tincture  of  iodine,  is  also  serviceable. 
These  remedies  may  be  quite  ettective  if  applied  early;  but 
after  the  disease  has  progressed  to  the  extremit}'  described, 
benefit  might  be  derived  from  cutting  away  the  iiypertrophied 
portion  with  a  point  in  a  burring  engine.] 

It  is  not  a  very  uncommon  occurrence  to  meet  with  the  two 
conditions  ju:^t  spoken  of  existing  together,  and  to  find  the  fang 
of  a  tooth  in  one  portion  hyperostosed  and  in  another  more  or 
less  absorbed. 


FITTING    ARTIFICIAL    CROWNS    TO    TEETH.  257 


[CHAPTER    XII. 

FITTING  ARTIFICIAL  CROWNS  TO  ROOTS  OF  NATURAL 

TEETH. 

In  all  cases  the  roots  should  have  been  treated  and  filled  a 
sufficient  time  to  insure  against  danger  from  inflammation 
or  abscess.  Often,  a  root  whose  surrounding  tissues  have 
been  tender,  and  threatening  chronic  inflammation,  will  be  re- 
stored to  a  comfortable  condition  by  regaining  the  normal 
stimulation  of  pressure  in  mastication. 

Pivot  teeth  are  made  of  porcelain,  in  a  great  variety  of  shapes, 
sizes,  and  shades,  to  suit  the  difl:erences  of  teeth  they  are  re- 
quired to  replace.  The  old  fashioned  teeth,  with  the  plain  hole 
in  the  centre,  to  be  made  continuous  with  the  pulp  cavity  of 
the  natural  root,  have  been  in  satisfactory  use,  and  are  likely  to 
continue  so  for  the  oral  teeth  for  many  years.  Natural  teeth 
crowns  were  at  one  time  in  vogue,  but  their  liability  to  putrefac- 
tion in  themouth, their  scarcity,  and  the  difliculty  of  getting  those 
that  were  satisfactory,  has  pretty  nearly  driven  them  out  of  use. 

In  selecting  a  tooth,  as  a  general  rule,  it  may  be  accepted  that 
the  less  prominent  it  is,  and  the  less  likely  to  attract  attention, 
the  better.  Hence,  of  two  shades,  one  a  little  too  dark  and  the 
other  as  much  lighter  than  the  original,  or  adjoining  teeth, 
the  former  is  to  be  preferred.  As  to  size,  much  depends 
upon  the  space  to  be  filled,  and  a  slight  exaggeration  of  the 
breadth  of  the  tooth  will  generally  be  less  noticeable  than  wide 
spaces  intervening  between  it  and  its  neighbors.  Care  must 
be  taken,  that  the  hole  for  the  pivot  is  well  shaped,  and 
in  such  position  as  to  be  continuous  with  that  of  the  root,  and 
while  sufficiently  large  to  admit  a  pivot  strong  enough  to  sup- 
port the  pressure  it  will  be  required  to  bear,  yet  it  should  not 
be  so  large  as  to  seriously  weaken  the  crown  or  root,  and  thereby 
defeat  its  object.  In  such  case  it  may  be  necessary  to  fit  a 
plate  tooth  and  back  it  with  gold,  or  thin  platinum  with  gold 
17 


258   MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY, 


Fig.  226. 


I 


IMUU 


Pivot  files  and  wheels. 

flowed  upon  it,  to  which  the  pivotof  gold  wire  maybe 
soldered  after  having  been  fitted  and  secured  in  situ 
upon  the  crown  by  wax  or  cement,  so  as  to  admit 
of  investment  in  sand  and  plaster  while  the  process 
of  soldering  is  completed. 

The  root  of  the  natural  tooth  should  be  filed  with 
a  lialf-round  pivot  file  (Fig.  226,  Nos.  40,  41,  or  42) 
to  a  curve  corresponding  with  the  festoon  of  the 
gum,  and  so  short  as  to  allow  the  joint  hetween  it 
and  the  crown  to  be  covered  by  the  gum  after  the 
latter  heals.  This  may  be  done  very  nicely  by  tlie 
stump  wheels  on  the  burring  engine. 

The  porcelain  crown  is  now  fitted  by  grinding 
until  the  joint  between  it  and  the  root  is  perfect,  and 
as  nearly  at  right  angles  to  the  force  of  mastication 
as  p>ossible.  The  crown  may  then  be  tried  with  a 
temporary  pivot,  made  of  a  soft  piece  of  wood,  but 
not  so  tightly  fitted  as  to  prevent  its  ready  removal 
when  in  place  and  moistened.  The  articulation 
with  the  opposing  teeth  should  then  be  studied,  and 
it  is  always  well  to  make  the  artificial  tooth  a  trifle 
short,  particularly  if  a  wooden  pivot  is  used,  as  it 
may  elongate  when  moistened. 

The  pivot  may  be  made  of  hickory  wood,  well 
seasoned  and  dried.  The  spoke  of  a  sound  old 
wheel  will  furnish  choice  material.  It  is  split  into 
small  [»ieces,  and  these  drawn  repeatedly  through  a 
wire  draw-plate  to  the  sizes  desired,  and  about  three 
inches  in  length.  The  size  of  the  hole  in  the  root  and  in  the 
crown  is  then  measured  with  a  steel  wire  or  a  wooden  match- 
stick,  drawn  in  the  same  manner,  only  that  it  may  be  slightly 
moistened.  After  fitting  it  as  to  the  length  and  diameter,  it 
will  serve  as  a  pattern  for  the  permanent  liickory  pivot. 


FITTING    ARTIFICIAL    CROWNS    TO    TEETH.  259 

The  latter  must  be  inserted  into  the  carefully  dried  porcelain 
crown,  and  then  pressed  into  the  hole  made  by  previously  ream- 
ing out  the  pul[»  canal. 

The  moisture  of  the  mouth,  or,  if  desired,  a  few  syringefuls 
of  water  thrown  around  the  neck  of  the  tooth,  will  cause  the 
wood  to  swell  and  hold  the  ci'own  firmly  and  at  the  same  time 
with  an  elasticity  rarely  equalled  by  more  modern  methods. 

There  has  been  much  said  against  the  wooden  pivots,  but  the 
writer  has  seen  them,  when  cut  off  in  the  root  and  exposed  for 
years,  serve  as  a  filling,  and  protect  the  cavity  quite  successfully. 
If  properly  made,  they  cannot  be  very  porous,  and  will  not  be 
such  receptacles  for  putrefaction  as  those  who  oppose  their  use 
would  have  us  believe,  while  their  elasticity  and  softness  pre- 
vent injury  to  the  dentine  of  the  root  from  chafing  or  wearing. 

When  it  is  desired,  a  gold  or  platinum  wire  may  be  fitted 
into  the  crown  and  held  there  by  packing  a  few  pieces  of  gold 
foil  around  it  and  then  flowing  solder  into  the  joint.  Taper- 
ing the  wire  slightly,  warming  and  covering  it  with  gutta 
percha,  it  may  be  pressed  up  into  the  root.  Sometimes  the  wire 
pivot  will  be  better  if  barbed. 

Several  roots  may  thus  be  pivoted  at  once  by  a  plate  with 
teeth  crowns  soldered  to  it ;  or  one  root,  with  the  assistance  of 
gold  clasps  around  adjoining  teeth,  or  wire  projections  into 
them,  may  be  made  to  sustain  two  or  three  crowns.  The  cavities 
in  which  the  projections  are  fitted  should  be  filled,  the  spaces 
being  completely  obliterated  by  gold  or  gutta-percha. 

The  Richmond  Croivns. — Dr.  C.  M.  Richmond  some  years  since 
devised  the  means  of  rendering  roots  serviceable  by  fitting  gold 
crowns  upon  them,  by  the  use  of  a  band  which  encircles  the 
necks  or  parts  of  the  roots  above  the  alveolar  processes  like 
ferrules.  These  seeming  slight  attachments  have  proven  sufli- 
cient  under  severe  use  in  a  great  number  of  cases.  Holes  may 
be  made  by  enlarging  the  pulp  canals,  and  gold  or  platinum 
screws  or  bolts  may  be  passed  through  the  crowns  down  to  the 
roots  to  serve  as  additional  stays. 

The  process  of  making  these  crowns  may  be  briefly  described 
as  follows: — 

The  gold  should  be  of  the  fineness  of  coin — for  convenience 
and  economy  the  five  dollar  gold  piece  is  the  best — and  should  be 


260   MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

of  the  dark  ricli  color  of  the  recent  U.  S.  coinage,  the  alloy  of 
which  is  mostly  copper.  The  coin  is  passed  through  the  rolling 
mill  until  reduced  to  about  No.  27  gauge,  which  makes  it  of  an 
elliptic  shape,  about  3  J  inches  long,  and  perhaps  a  trifle  wider  than 
the  original  coin.  The  ends  and  sides  are  now  pared  off  to  bring 
the  plate  to  a  rectangular  shape,  and,  after  weighing,  the  parings 
are  melted  upon  a  piece  of  jeweler's  charcoal,  and  one-fifth  of 
their  weight  of  fine  brass  wire,  cut  into  pieces  about  half  an  inch 
in  length,  is  added.  Care  must  be  taken  that  the  melted  gold 
is  well  covered  with  flux  (borax)  to  prevent  the  burning  of  the 
brass,  which  latter  may  be  added  piece  by  piece  at  a  time,  so  as 
not  to  chill  the  button  too  rapidly,  one  end  of  each  being  pushed 
into  the  molten  button.  This  forms  the  solder,  which  is  rolled 
df)wn  to  about  the  thickness  of  the  plate,  and  cut  into  small 
pieces  as  wanted  for  use. 

The  root  is  prepared  by  filing  or  grinding  with  the  stump  cor- 
undum wheels  or  tiles  to  flatten  the  exposed  end.  A  strip  of  the 
plate  is  cut,  wide  enough  to  reach  from  the  alveolar  process  to  a 
little  above  this  end  of  the  root,  and  long  enough  to  encircle  the 
same;  for  this  a  pattern  of  soft  lead  or  tin  foil  may  be  tried  and 
made  as  a  guide.  This  strip  of  gold  plate  is  now  bent  and  filed 
so  as  to  make  a  close  fitting  ferrule;  indeed,  it  may  be  made  a 
trifle  smaller,  say  two  or  three  times  the  thickness  of  the  plate, 
as  it  is  liable  to  stretch,  the  ends  abutting  edge  to  edge,  and 
these  soldered  together.  A  piece  of  [)late  large  enough  to  cover 
the  upper  or  crown  end  of  the  ferrule  is  now  cut,  and  a  small 
piece  of  the  solder  flowed  over  one  side  of  it,  when  it  is  laid, 
with  the  soldered  side  down,  upon  the  end  of  the  ferrule,  properly 
covered  with  borax  ground  in  water  to  the  consistence  of  cream, 
and  by  heating  to  the  melting  point  of  the  solder,  the  blowpipe 
flame  being  thrown  down  u[»on  it,  this  lid  or  end  is  united  with 
the  ferrule  proper.  With  the  file  the  edges  of  tlie  lid  are  dressed 
down  level  with  the  ferrule,  the  outside  is  smoothed,  and  the  end 
next  the  bone  has  the  proximate  surfaces  cut  away  with  a  round 
file  to  correspond  with  the  festoons  of  the  gums  and  septa  of 
bone  between  the  teeth,  where  they  hang  lower.  The  edge  next 
the  gum  is  then  slightly  beveled  from  the  outside,  making  a 
chisel  or  gouge-like  edge  to  pass  up  around  the  root  and  in  the 
closest  contact  with  it.  The  ferrule  is  now  placed  upon  the  root 
and  pushed  or  driven  home,  and  the  [)oints  for  putting  on  the 


FITTING    ARTIFICIAL    CROWNS    TO    TEETH.  261 

cusps  of  the  crown  are  marked.  Buttons,  made  by  melting 
scraps  of  the  coin,  are  first  sliojhtly  flattened  by  the  blows  of  a 
hammer,  while  they  are  lying  upon  a  smooth  steel  surface,  then 
tried  as  to  size  and  shape,  allowing;  a  very  slight  thickness  for 
grinding  off,  to  perfect  the  occlusion  or  biting  against  the  an- 
tagonizing teeth,  after  the  crown  is  finally  placed.  The  part  of 
the  ferrule  that  is  to  be  next  the  lip  or  cheek  may  have  a  slight 
mark  scratched  upon  it  for  the  sake  of  convenience  in  replacing 
the  crown,  and  the  ferrule  may  then  be  drawn  off  from  the  root 
by  working  it  down  with  a  dull  hoe  excavator,  being  careful 
not  to  nick  the  edge  of  the  gold  or  scratch  the  tooth. 

The  ferrule  should  now  be  solidly  filled  with  moistened  sand, 
to  which  a  little  plaster  has  been  added,  as  for  investing  plates 
and  artificial  teeth  for  soldering,  and  the  whole,  excepting  the 
top  or  lid,  should  be  embedded  in  a  slightly  conical  mass  of  the 
same.  The  buttons  to  form  the  cus|)S  should  be  placed  in  posi- 
tion on  the  lid  of  the  ferrule  as  soon  as  the  plaster  has  dried,  the 
solder  piled  up  around  the  buttons,  and  the  whole  covered  with 
the  borax  flux.  To  attach  the  mass  it  must  now  be  heated  by 
the  blowpipe  until  the  solder  is  melted  and  flows  freely,  forming 
a  perfect  crown  in  shape  ;  but  care  must  be  exercised  not  to  flake 
ott'  the  plaster  investment  and  expose  to  the  flame  the  soldered 
portion  of  the  work  already  finished,  lest  the  ferrule  come  out 
from  this  heating  defective,  or  with  a  hole  burned  through  it. 
The  crown  is  now  shaped,  smoothed,  and  afterwards  polished 
upon  a  felt  wheel,  it  being  held  in  contact  with  the  latter  by  a 
stick  fitted  into  the  open  end  of  the  ferrule.  Care  must  be  taken 
that  we  may  be  able  to  recognize  readilj"  the  buccal  or  labial 
side  either  by  the  cusps  or  by  allowing  the  scratched  mark  to 
remain.  In  cases  where  the  {ippearance  of  the  gold  is  objection- 
able a  plain  porcelain  tootli  of  pro[)er  shade  may  be  fitted,  backed, 
and  soldered  on  in  the  place  of  the  outside  cusp  or  cusps,  and  in 
such  teeth  it  is  best  that  the  ferrule  should  not  come  below  the 
free  margin  of  the  gum  upon  the  labial  face. 

A  small  hole  may  now  be  drilled  into  the  hollow  portion  at 
a  convenient  point  of  entrance  from  the  outside,  affording  escape 
for  the  cement  when  the  crown  is  being  pressed  into  position. 
The  root  and  surrounding  gum  being  well  wiped  and  kept 
thorougiily  dr}^  by  means  of  a  folded  napkin,  the  interior  of  the 
ferrule  is  filled  with  some  plastic  filling  materials,  oxy-chloride 


262 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


or  oxyphosphate  of  zinc,  mixed  rather  thinner  than  usual  for 
insertion  into  cavities.  The  crown  is  then  to  be  pushed  upon  the 
root  and  a  bite  taken  by  the  patient  to  force  it  to  its  place  be- 
fore the  cement  filling  has  set,  where  it  should  be  held  im- 
movable until  the  plastic  filling  has  hardened.  The  overflow 
opening  may  then  be  filled  with  gold.  The  crowns  may  then 
be  ground  with  the  corundum  points  on  the  dental  engine  until 
the  articulation  is  perfect. 

The  writer  has  worn  with  great  satisfaction  for  nearly  three 
years  two  teeth  made  as  described,  and  with  them  he  breaks  up 
the  hardest  substances  ordinarily  used  as  food,  preferring  to 
risk  the  gold  crowns  rather  than  frail  natural  ones. 

Drs.  Grates  and  Bonwill's  crowns  are  made  of  porcelain. 
After  being  ground  to  fit  the  previously  smoothed  stump,  and 
articulate  properly  with  the  antagonizing  teetli,  they  are  held 
in  position  by  three-cornered  barbed  platinum  wires,  which  have 
been  secured  in  the  roots  by  driving  them  in,  and  filling 
around  them.  The  spaces  left  between  the  platinum,  the  crowns, 
and  the  roots  are  filled  with  a  quick-setting  amalgam  or  gutta- 
percha. 


Gates-Bonwill  crowns. 


The  Flagg  pivot  is  explained  in  the  following  terse  descrip- 
tion in  his  own  words:' — 

"Select  plate-tooth,  fit  it  to  root,  and  bevel  it  from  near  the 
pin — cervical — or  pins,  if  cross-pins,  to  the  labio-cervical  edge. 
tSolder  a  platinum  pin  to  it  as  a  backstay  and  pivot  combined, 
leaving  it  rou£i;li  or  grooved  on  both  sides  of  the  pin  for  a  retain- 

COO  i- 

ing  hold  to  the  finishing  palatal  amalgam. 

''  Fill  the  root,  which  is  treated,  prepared  for  strong  mainte- 
nance of  filling,  and  '  bell-muzzled,' or  '  open-mouthed,' with  a 
good  usual  or  contour  alloy,  quick  setter,  non-shrinker,  good 
edge,  strength.    I  prefer  to  give  this  a  day  to  iiarden  thoroughly, 


['  See  p.  129,  Plastics  and  riaslic  Filling.] 


FiTTINQ     ARTIFICIAL    CROWNS    TO    TEETH.  263 

but  in  case  of  need  it  may,  with  care,  be  worke-l  in  an  hour  or 
two. 

"Into  the  root  filling  drill  a  hole  rather  larger  than  the 
platinum  pin,  as  near  to  the  pdatal  portion  of  the  filling  as 
possible,  and  directed  slantwise  to  the  a[>ical  centre  of  root-fill- 
ino-;  then  fissure-drill  the  hole  towards  the  labial  portion  of  the 
filling,  trying  the  tooth  until  it  sets  just  right,  with  the  pivot- 
pin  pressing  hard  against  the  labial  side  of  the  now  oval  pivot 
hole.  B>/  this  method  the  tooth  is  accurately  placed  in  position  and 
easily  held  firmly  in  place  while  the  pin  is  secured  by  filling  the  pivot 
hole  with  amalgam. 

"Let  this  harden  for  half  an  hour,  and  then  add  amalgam  in 
contour  to  the  root  filling  and  palatal  face  of  the  porcelain  tootii. 
It  is  at  this  point  of  the  operation  that  the  need  for  '  bevelling' 
the  cervical  portion  of  the  tooth  is  demonstrated,  for,  by  this 
bevel,  one  is  enabled  to  make,  by  filling,  a  perfectly  tight  joint 
at  the  labio-cervical  junction  of  tooth  with  root,  and  also  to 
secure  a  strength  of  amalgam  equal  to  the  entire  surface  of 
root-filling." 

There  yet  remains  for  notice  an  ingenious  practice  described, 
by  Dr.  Bing,  of  Paris,  for  filling  or  restoring  large  portions  of 
crowns.  A  thin  plate  of  pure  gold  is  struck  up  to  the  shape 
desired  to  be  placed  upon  the  tooth,  and  upon  the  under  side  is 
soldered  by  the  ends  two  pieces  of  wire  shaped  like  staples. 
After  fitting  this  gold  cap  or  cover,  the  tooth  is  filled  with 
gutta-percha,  and  while  it  is  yet  soft,  the  cap  is  warmed  and 
pressed  into  place,  and  burnished  down  to  fit  tightly  and  pro- 
tect the  edges  of  the  tooth  and  the  wiiole  filling.  The  cavity 
in  the  tooth  may  be  rounded  in  contour,  the  edges  smoothed 
and  polished,  so  as  to  enable  the  operator  to  burnish  the  gold, 
to  form  a  tight  and  close-fitting  joint.] 


264   MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


CHAPTER    XIII. 

EXTRACTION  OF  TEETH. 

The  operation  of  extraction  bears  an  analogy  to  that  of  am- 
putation, inasmuch  as  it  is  the  removal  of  a  useless  or  obnox- 
ious member  for  the  welfare  of  the  rest.  As  no  conscientious 
surgeon  would  ever  think  of  resorting  to  the  latter  so  long  as 
any  well-grounded  hope  existed  of  a  limb  or  member  being 
again  restored  to  a  state  of  usefuhiess,  so  no  intelligent  dentist 
will  ever  think  of  extracting  a  tooth  as  long  as  there  remains  a 
fair  prospect  of  its  also  being  restored  to  a  state  of  usefulness. 
On  the  other  hand,  the  surgeon  knows  that  an  artificial  limb, 
however  limited  its  capabilities,  is  yet  infinitely  better  than  a 
painful  and  useless  one ;  and  the  dentist  likewise  knows  that 
an  artificial  tooth  is  infinitely  better  than  a  useless  and  painful 
one.  In  another  point  of  view,  however,  the  two  operations 
widely  differ,  viz. : — in  their  effects  upon  the  individual,  the  one 
being  comparatively  safe  and  almost  momentary  in  point  of 
duration,  the  other  being  severe  in  character,  and  highly  dan- 
gerous in  its  results  ;  at  the  same  time,  this  ought  in  no  way  to 
lessen  a  due  consideration  before  sacrificing  so  useful  though 
humble  a  member  as  a  tooth,  and  this  consideration  becomes  of 
still  more  importance  when  the  tooth  or  teeth  to  be  removed 
happen  to  be  sound  ones. 

The  teeth,  about  the  removal  of  which  we  hesitate  the  least, 
are  those  which  have  become  so  loose  from  absorption  of  their 
alveoli  as  to  be  quite  useless,  indeed  impediments  to  mastica- 
tion ;  those  long  affected  with  chronic  periodontitis,  whose 
tartar-crusted  crowns  are  evidence  of  their  long  season  of  useless- 
ness,  as  well  as  that  of  their  immediate  neighbors  ;  teeth  erupted 
in  abnormal  jiositions,  incapable  of  being  brought  into  position, 
and  interfering  with  movements  of  the  tongue  or  lips;  also 
the  roots  of  teeth  causing  unhealthy  gums  or  secreting  offensive 
■fluids.     [The  method  of  fitting  artificial  crowns  has,  however, 


EXTRACTION    OF    TEETH.  265 

rendered  the  preservation  of  roots  a  matter  of  much  importance, 
and  to-day  many  such  are  in  constant  and  highly  satisfactory 
use.] 

Having  convinced  ourselves  of  the  expediency  of  resorting  to 
extraction,  we  must  in  its  performance  carefully  observe  three 
conditions:  first,  to  carry  it  out  completelj',  in  other  words,  to 
remove  the  tooth  in  its  entirety;  secondly,  to  accomplish  it 
with  the  least  possible  injury  to  surrounding  parts;  and  thirdl}^ 
to  inflict  as  little  pain  as  possible.  Usually  carefully  pursuing 
the  second  condition,  we  fulfil  the  third.  The  form  of  articula- 
tion of  the  teeth  to  the  jaws  has  been  classicall}'  termed  gom- 
phosis,  but  this  gives  an  erroneous  idea  of  the  exact  attach- 
ment; the  teeth  are  not  retained  in  their  sockets  as  are  nails  in 
wood,  by  their  elastic  surroundings.  In  a  dried  skull  the  teeth 
will  be  felt  loose  in  their  alveoli ;  some  will,  itideed,  drop  out 
by  their  own  weight;  the  rest  are  retained  by  tlie  dovetailing 
of  their  fangs  in  their  sockets.  It  is  a  strong  periosteum,  the 
alveolo-dental  membrane,  which  is  the  true  medium  of  attach- 
ment of  the  teeth  and  maxillae,  and  it  is  the  sundering  of  this 
which,  in  normal  cases,  necessitates  the  amount  of  force  that 
must  be  employed,  and  which  should  occupy  our  chief  atten- 
tion, the  thin  alveolar  walls  in  the  moist  condition  yielding 
more  readily. 

\_Extraction. — The  peculiar  nervous  condition  into  which  most 
patients  find  themselves  brought  by  the  suffering  which  precedes 
and  often  compels  the  operation  of  extraction,  entitles  them  to 
the  most  sympathetic  consideration  of  the  dentist  and  to  his  most 
gentle  efforts  for  their  relief.  Weak  children,  delicate  women, 
and  sturdy  men  alike  succumb,  and  lose  all  self-control  in  the 
face  of  the  expected  torture,  and  no  amount  of  ordinary  faith  or 
courage  will  suffice  to  keep  down  their  agitation  and  quiet  their 
expressions  of  dread. 

To  deal  with  such  conditions  requires  peculiar  gifts  on  the 
part  of  the  dentist,  which  are  so  rare  as  to  make  their  possessor 
both  well  known  and  successful.  lie  must  have  confidence, 
which  can  only  be  well  founded  by  a  thorough  knowledge  of 
his  subject;  his  movements  must  be  rapid  but  easy  ;  his  manner 
firm  but  patient;  above  all  his  symjiathy  must  be  genuine. 

The  anatomy  of  the  teeth  and  surrounding  j^arts. — In  this  study 
we  first  note  the  insertion  of  their  roots  (for  description  of  which 


266    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOaY. 

see  pages  49  and  50)  into  a  more  or  less  spongy  bone,  with  an  ex- 
ceedingly tough  membrane  uniting  the  two,  and  which  may  be 
slightly  thickened  about  the  necks  of  the  teeth,  forming  the  so- 
called  ligamentiim  dentis,  which,  however,  is  of  so  slight  im- 
portance from  an  operative  standpoint  that  we  may  remind  the 
student  that  its  existence  is  doubted  by  some. 

Fiff.  228. 


The  teeth  of  the  left  side  of  the  mouth. i 


A  little  below  the  bottom  of  the  cavity  in  which  the  tooth 
fits,  which  is  called  the  alveolus,  we  find  in  the  living  bone  an 
artery  which  gives  oft"  minute  filamentary  branches  to  enter  the 
apex  of  each  root,  and  with  this  passes  also  a  nerve  and  vein  of 
like  proportions.  At  the  back  part  of  the  upper  jaw-bone,  im- 
mediately behind  and  above  the  last  tooth,  is  a  tuberosity  which 
is  richly  supplied  with  blood  from  several  branching  vessels  of 
the  alveolar  artery,  entering  by  small  holes  or  foramina,  the 
largest  is  the  superior  dental  artery.  Traversing  the  body  of  the 
bone  almost  per[)endiciilarly  is  a  branch  of  the  infra-orbital  ar- 
tery, which  it  leaves  in  the  canal  under  the  orbit  and  descending 
sends  small  twigs  to  the  upper  incisors  and  antrum,  a  cavity  in 
the  bone  connecting  with  the  nose  and  formed  immediately 
above  the  molars,  whose  roots,  covered  with  a  thin  layer  of  bone 
and  mucous  membrane,  often  project  into  it.    This  cavity  may  be 


'  From  "Tlie  Mouth  ami  tlic  Teeth."     By  Dr.  Jas.  W.  White,  Philadelphia. 


EXTRACTION    OF    TEETH.  26T 

opened  into  by  the  extraction  of  one  of  these  teeth,  or  it  may 
be  diseased  and  involve  them,  but  lined  with  mucous  membrane 
like  that  of  the  nose,  its  .being  opened  by  accident  in  extrac- 
tion is  not  of  necessity  a  serious  matter. 

In  disease  such  opening  serves  as  an  avenue  for  treatment,  and 
is  often  purposely  made. 

Two  bloodvessels,  one  on  either  side,  are  to  be  found  running 
forward  from  the  posterior  part  of  the  palate,  nourishing  that 
portion  between  the  teeth  which  is  commonly  called  the  roof  of 
the  mouth  ;  they  pass  upward  to  the  nose  through  the  anterior 
palatine  canal  which  is  in  the  anterior  portion  of  tlie  upper  jaw 
immediately  behind  the  central  incisors. 

In  the  lower  jaw  the  inferior  dental  artery,  a  branch  of  the 
internal  maxillary,  enters  the  bone  on  the  inside  of  the  ramus  by 
the  inferior  dental  foramen,  the  opening  of  a  canal  in  the  bone 
through  which  it  passes  forward  to  the  neighborhood  of  the 
root  of  the  second  bicuspid  where  it  divides.  One  branch,  the 
inferior  incisor,  passes  forward  to  nourish  the  anterior  part  of 
the  bone  and  oral  teeth  ;  the  main  stem,  diminished  in  size,  and 
now  called  the  mental  artery,  finds  an  exit  on  the  labial  side  of 
the  bone  to  nourish  the  lower  lip  and  gums. 

The  tongue  is  a  highly  vascular  organ,  having  two  arteries, 
the  ranine,  running  parallel  from  its  base  on  the  underside  to- 
ward its  tip,  and  two  above,  the  dorsali  lingupe.  The  arteries 
above  named  anastomose  toward  their  terminations.] 

In  proceeding  to  consider  the  operation  of  extraction,  it  is 
desirable  that  we  should  first  describe  the  instruments  employed, 
and  in  tlius  doing  we  shall  merely  allude  to  one,  which, 
though  serviceable  in  its  day,  should  now  possess  only  historical 
interest.  The  key  (Fig.  229),  so  largely  employed  for  many  years, 
is  now,  or  at  least  should  be,  entirely  superseded  by  other  and 
more  efficient  instruments. 

It  formed,  when  in  action,  a  most  powerful  lever  of  the  first 
order,  and  therefore  became,  especially  in  inexperienced  hands, 
a  dangerous  instrument ;  moreover,  when  it  was  once  ap- 
plied to  a  tooth,  the  force  exerted  could  be  in  only  one  given 
direction,  and  this  might  happen  to  be  that  in  which  the  greatest 
resistance  was  offered  ;  and  lastly,  as  the  fulcrum  of  the  instru- 
ment was  apitlied  upon  a  soft  tissue — the  gum  ;  this,  although 
it  might  be  relieved  by  padding,  had  to  bear  the  force  necessary 


268   MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

for  removing  the  tooth,  mostly  bruising  it,  sometimes  lacerating 
it.  [Some  operators  were,  however,  quite  expert  in  its  use,  by 
placing  the  fulcrum  upon  the  tooth,  and  thus  avoiding  the  in- 
jury to  the  gum.] 

To  the  great  improvements  in  the  forceps  is  due  the  retire- 
ment of  the  key,  which  was  not  an  improper  instrument  so 
long  as  the  forceps  employed  was  not  adapted  to  be  accurately 

Fis:.  229. 


Key  instrument  for  extracting  teeth.  The  upper  portion  represents,  on  the  ri^ht  hand,  tlie 
bolster  or  fulcrum,  and  on  the  left  hand  a  claw  which  revolves  upon  a  screw  shown  at  quite  the 
extremity.  The  steel  bar,  which  connects  this  portion  with  the  handle,  is  bent,  so  as  to  permit  it 
to  clear  the  front  teeth.  The  detached  claws  represent  different  widths  for  application  to  larger 
or  smaller  teeth. 


applied  to  each  tooth,  and,  therefore,  touching  only  at  a  few 
points,  acted  mostly  like  a  cutting  instrument,  either  slipping 
oft"  from,  or  fracturing,  the  crown.  The  point  is  well  illustrated 
in  the  case  of  the  litters  of  gas  and  water  [tipes,  whose  pincers 
or  tongs,  being  segments  of  circles  at  their  grasping  points, 
securely  hold  the  circular  pipes,  which  ordinary  pincers  would 
only  slide  upon  or  crush.  Changes  in  apjiliances,  as  in  ideas, 
are  mostly  gradual;  many  practitioners,  knowing  the  disad- 
vantages of  the  key,  endeavored  to  rerned}'  the  evil  by  adapt- 
ing the  existing  forceps,  as  far  as  })0ssible,  to  certain  teeth,  l)ut 
the  key  received  its  death-blow  when  J.  Tomes  took  in  hand 
not  only  the  construction  of  forceps  ada[)tablc  to  every  tooth. 


EXTRACTION    OF    TEETH.  269 

but  conferred  tlie  greater  benefit  of  enabling  practitioners  to 
obtain  the  same,  a  privilege  of  which  every  dentist  of  the 
present  day  should  not  be  unmindful ;  and  the  public  may  also 
rejoice  that  from  the  time  he  did  so  the  excruciating  "  key  note" 
has  gradually  faded  from  the  surgeries  of  dentists. 

The  forceps  is  a  modified  pair  of  pincers  (Fig.  230),  and  con- 
sists essentially  of  the  same  parts,  viz.,  a  pair  of  blades  or  jaws 

Fi?.  230. 


Forceps  for  extractiiii,'  upper  incisor  and  ciispi<lati  teeth.     The  hlades  at  the  upper  portion  of 
the  instrument  are  contiected  with  the  tiandles  at  the  lower  portion  by  the  round  hinge. 

with  handles  which  meet  and  cross  each  other  at  the  hinge : 
each  half  becomes  a  lever  of  the  first  order,  having  its  common 
fulcrum  at  the  hinge,  and  this  fact  should  always  be  remem- 
bered in  grasping  a  tootli,  which  is  a  tube,  and  often  a  very 
fragile  one. 

The  instrument,  it  need  hardly  be  mentioned,  should  be  of 
excellent  steel,  and  the  bhides,  or  grasping  portion,  so  tempered 
as  to  slightly  bend  rather  than  break  if  any  very  unusual  force 
be  encountered.  Besides  being  made  to  fit  accurately  to  the 
neck  of  the  tooth,  for  which  the  instrument  is  constructed,  they 
should  be  thin  and  sharp  at  their  edges,  so  as  to  detach  the  gum 
from  the  neck  of  the  tooth,  and  even,  if  desired,  enter  between 
the  root  of  the  tooth  and  its  alveolus.  When  closed  upon  a  tooth, 
the  blades  should  rest  parallel  with  its  neck  for  some  short 
distance,  and  not  merely  touch  it  with  their  edges,  and  be  quite 
free  from  impinging  upon  the  crown,  a  fault  sometimes  over- 
looked at  the  present  day  ;  and,  giving  sufiScient  room  for  the 
crown,  they  should  be  no  longer  than  is  absolutely  necessary, 
as  power  is  thereby  lost,  the  long  blades  often  bending  upon  the 
neck  of  a  very  firm  tooth  instead  of  moving  it.  In  the  con- 
struction of  the  hinge,  care  should  be  exercised,  not  only  that  it 
is  strong,  but  that  it  is  not  liable  when  closed  to  include  por- 
tions of  the  lips,  tongue,  or  cheek.  The  round  form  devised  by 
T>.  George,  now  generally  seen,  has  the  latter  advantage  to  per- 
fection, but  it  fails,  we  think,  in  not  affording  a  little  lateral 


270    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

movement.  In  cojistructing  the  adapted  forceps,  it  is  usual, 
after  forging  and  filing  the  blades  as  nearly  to  the  required 
shape  as  possible,  to  fit  them  still  more  perfectly  by  applying 
them  to  the  neck  of  a  normally  formed  tooth,  colored  with  pig- 
ment ;  the  spots  marked  by  the  pigment  are  cut  away,  and  the 
process  continued  until  an  almost  perfect  adaptation  is  attained, 
after  which  the  blades  are  tempered.  Thus  constructed,  the 
blades  should  accurately  fit  upon  the  external  and  internal  sur- 
faces about  the  neck  of  the  tooth ;  but,  as  these  do  not  always 
bear  the  same  relative  position  to  each  other,  it  is  well  to  have 
a  little  play  at  the  hinge,  which  will  allow  of  the  blades  accom- 
modating themselves  to  this  departure.  The  handles  should  be 
strong,  broad,  and  roughened,  long  enough  to  aftbrd  a  firm 
grasp,  but  no  more,  for  although  length  in  the  handles  gives 
greater  leverage,  they  make  the  instrument  cumbrous,  and 
interfere  with  delicacy  of  movement. 

[Forceps  for  the  ojieration  of  tooth  extraction  should  be  gene- 
rally straight,  or  so  nearly  so  as  to  make  the  force  applied 
to  be  in  a  direct  line  with  the  axis  of  the  tooth.  Manufac- 
turers are  still  compelled  to  satisfy  a  demand  for  various 
tAvisted  and  curved  implements  which  remain  in  favor  with 
many.  Hooked  handles  on  forceps  is  an  example  of  the  power 
of  conservatism  ;  except  the  hooks  be  upon  both  handles,  the 
tendency  is  to  cause  the  force  exerted  to  press  to  one  side,  chang- 
ing the  direction  to  an  oblique  one  with  the  axis  of  the  tooth. 
Forceps  cannot  be  selected  ready  made  without  these  cumber- 
some contrivances,  and  therefore  the  student  must  pardon  their 
appearance  in  the  illustrations. 

The  beaks  of  the  forceps  as  now  sold  are  generally  good  as 
regards  their  shape,  but  in  selecting  it  may  not  be  amiss  to  test 
them  upon  typical  teeth  of  the  kind  for  which  the  forceps  are 
designed. 

By  many  the  joints  are  preferred  of  an  oval  form,  being 
stronger  and  likewise  less  liable  to  wound  the  lips  or  cheeks,  if 
the  patient  struggles. 

In  indicating  what  may  be  called  a  set  of  forceps  it  has  been 
the  endeavor  to  name  them  in  the  order  of  their  relative  value. 

Fig.  231  is  an  incisor  forceps,  which  has  the  qualities  de- 
scribed, being  straight  in  its  axis,  and  although  not  shown  in 
the  cut,  can  be   purchased  with   oval  joints  and  straight  ban- 


EXTRACTION    OF    TEETH, 


271 


dies.     This  instrument  is  of  use  often  as  far  back  as  the  bicuspids, 
and  although  intended  for  incisors  only,  it  is  used  by  many  even 


Fiff.  231. 


Xo.  13.     Superior  incisor  forceps. 

for  molars,  but  in  all  cases  except  for  the  teeth  for  which  it  is 
desi!ij;ned,  the  danger  of  fracturing  the  crowns  must  not  be  over- 
looked. 

Fig.  232  is  designed  for  lower  bicuspid  teeth,  but  may  serve 
well  for  incisors  by  grasping  the  tooth  upon  the  lip  and  tongue 
sides  and  making  the  motion  forward  and  backward,  instead  of 
from   right  to  left  as  in   the  bicuspids.      Molars   may  in  like 

Fiff.  232. 


No.  21.     Inferior  incisor,  canine  and  bicuspid  forceps. 

manner  be  extracted  with  it  if  not  too  firm  in  their  sockets  and 
by  turning  the  beaks  up  the  suj^erior  molars  and  wisdom  teeth 
may  be  grasped  with  it. 

Fia;.  233. 


Xo.  tS.    UppiT  molar  forceps  for  either  sidr 


Fig.    233    and   Fig.    234   are,   better   adapted   to   all    upper 
and   lower   molars,  except   perhaps   the  wisdom    teeth.      The 


272   MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOaY. 

former  (Fig.  233),  having  one  beak  with  a  point  for  passing  be- 
tween the  buccal  roots,  and,  being  perfectly  straight,  may  be  used 

Fi?.  234. 


No.  17.     Lower  molar  forceps  for  either  side. 

upon  either  side  by  placing  the  pointed  beak  outward  or  next 
the  cheek.  The  latter  (Fig.  234)  can  be  seen  at  a  glance  to  be 
adapted  to  pass  its  pointed  beaks  between  the  two  roots  of  a 
lower  molar  on  either  side. 

Fig.  235  is  well  designed  for  upper  roots,  being  often  service- 
able all  around,  occasionally  even  in  the  lower  jaw. 

Fig.  235. 


No.  7.     Root  forceps. 


Fig.  236,  in  cases  of  upper  second  molars  and  wisdom  teeth, 
will  complete  the  set  of  six  that  are  most  useful  and  essential, 


Fig.  236. 


No.  10.     Upper  molar  and  wisdom  teetli. 

and  without  which  one  need  hardly  hope  to  gain  a  very  ex- 
tended practice,  if  any  other  dentist  be  accessible,  unless  he  too  is 
poorly  provided. 

To  the  above  set  might  well  be  added  Fig.  237,  a  forceps 
designed  by  the  writer  for  cutting  out  the  roots  without  remov- 


EXTRACTION    OF    TEETH. 


273 


ing  a  portion  of  the  bone;  for  separating  hooked  roots,  so 
tliat  they  may  be  extracted  separately  ;  also  to  use  as  elevators 
for  wedging  between  wisdom  teeth  and  second  molars.  In 
the  latter  use  care  must  be  taken  to  support  the  fulcrum  tooth, 


Fisr.  237. 


No.  66.     Forceps  for  cutting  out  the  roots. 

if  there  be  no  tooth  immediately  in  front,  by  placing  a  small 
piece  of  w^ood  to  impinge  on  it  and  the  next  one  to  the  front. 
A  little  caution  will  likewise  be  necessary  to  prevent  the  turn- 
ing of  the  wisdom  tooth  so  completely  out  of  its  socket  as  to 
liave  it  pushed  back  into  the  fauces ;  particularly  should  this 
be  observed  if  the  patient  be  under  an  anaesthetic. 

To  these  forceps  may  be  added  with  great  advantage  some 
few  others,  which,  although  not  so  frequently  required,  will 
well  repay  the  first  cost  by  the  satisfaction  of  having  them  at 
liand  when  wanted.  Extraction  is  an  operation  that  must  be 
performed  with  confidence  on  the  part  of  the  operator,  and  no 
better  rule  has  been  given  for  it  than  that  of  Tomes.  "The 
whole  of  the  tooth  should  be  removed  with  as  little  injury  as 
possible  to  the  surrounding  structures  and  the  least  pain  ne- 
cessary to  the  case,"  Digging  out  a  tooth  piece-meal,  or  other 
barbarities,  such  as  are  practised  by  the  African,  who  relieves 
his  companion  of  an  aching  tooth  by  means  of  a  spear-head  for 
an  instrument,^  cannot  come  under  the  classification  of  dentistry. 
Blacksmiths'  tongs,  cold  chisels,  and  hammers  have  been  used 
for  the  purpose  successfullv,  but  are  no  more  to  be  reprehended 
than  some  of  the  methods  the  writer  has  seen  and  heard  of  as 
adopted  by  dentists. 


['  It  was  related  to  the  writer  by  Dr.  Visick,  of  England,  that  one  of  his 
relatives  had  actually  witnessed  such  an  operation.] 
18 


274    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

Therefore,  as  auxiliary  to  the  above  list  of  seven  instruments, 
every  practising  dentist  will  do  well  to  furnish  himself  with 
the  following  : — 

Fig.  238,  upper  molar  forceps,  right  and  left.  In  these  are  found 
a  deviation  from  the  straight  line  so  urgently  recommended, 

Fiir  238. 


No.  18.     R.  &  L.  upper  molar  forceps. 

but  to  enable  the  operator  to  reach  well  back  in  mouths  with  a 
small  opening,  they  w^ill  very  frequently  be  found  desirable,  if 
not  absolutely  necessary. 

Fig.  239,  root  forceps.   The  cut  represents  a  pair,  rather  heavy 
for  the  purpose  designed.     For  the  operator  who  is  content  to 

FijT.  239. 


No.  1.     Koot  lurceps. 

consider  the  possible  fracture  of  an  instrument  as  of  more  im- 
portance than  the  pain  inflicted  by  forcing  up  the  beaks  between 
the  root  and  gum,  it  may  do.  There  are,  however,  more  deli- 
cate instruments  made  than  the  one  figured,  and  if  specially 
ordered,  they  can  be  made  so  light  as  to  be  capable  of  passing 
between  the  root  and  bone  with  a  surety  of  success  in  the  re- 
moval of  the  root. 

Fig.  240,  right  and  left,  is  the  cut  of  a  pair  of  instruments 
that,  although  rarely  used,  are  very  valuable  in  extreme  cases 
where  the  crowns  are  so  far  crumbled  away  or  weakened  as  to 


EXTRACTION    OF    TEETH.  275 

l)e  incapable  of  resisting  a  force  sufficient  to  remove  the  teeth. 
The  horn-like  beak  passes  between  the  buccal  roots,  and  should 

Fi,-;.  241). 


No.  20.     II.  &  L.  ujiiier  nicjlui-  forceps. 

either  bring  them  away  or  divide  them  so  that  with  the  curved 
or  universal  root  forceps,  Fig.  235,  they  may  be  susceptible  of 
removal. 

Fig.  241  is  the  low^er  forceps  designed  for  the  same  purpose 
in  the  lower  jaw.     It  is  not  an  unfrequent  experience  that  the 

Fiir.  241. 


No.  2.3.     Lower  molar  forceps,  either  side. 

mere  closure  of  the  beaks  between  the  roots  will  wedge  the 
whole  tooth  out  of  its  socket,  and  to  complete  the  operation  it 
is  only  necessary  to  lift  it  out  of  the  mouth. 

Fig.  242  is  a  cutting  forceps  for  the  upper  jaw,  corresponding 
in  its  use  to  that  of  Fig.  287,  adapted,  liowever,  by  the  curve,  to 
reach  back  to  the  upper  molars,  and,  b}^  cutting  through  the 
bone,  seizing  and  removing  their  roots.  The  gum  may  be  di- 
vided first  by  the  lancet  upon  either  side  of  the  root ;  an  unneces- 
sary operation  if  the  patient  is  anaesthetized. 

The  advantage  of  these  instruments  over  those  that  have 
double  cutting  edges  on  each  beak  is,  that  the  healing  is  much 
more  promptly  eiiected  than  when  a  mass  of  bone  is  removed, 


276    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

and  at  the  same  time  the  alveolar  process  is  not  lost — a  great  de- 
sidenitum  when  the  patient  is  to  wear  an  artificial  substitute. 

Fiir.  243. 


No.  67.    Cutting  forceps. 


Fig.  243  is  a  smaller  size  of  incisor  forceps,  which  will  answer 
in  case  of  laterals  or  very  small  teeth.    As  mentioned  before,  it 


Fiff.  343. 


No.  48.     Lateral  incisor  forceps. 


is  often  desirable  to  have  more  than  one  size,  as  the  incisors  var}- 
so  much  that  one  pair  of  forceps  cannot  be  relied  upon  to  fit  all 
cases  with  accuracy  sufficient  for  their  removal  without  acci- 
dent or  fracture. 


Fiff.  344. 


No.  40.     Lower  iiici.sur  and  rucit  forceps. 


Fig.  244  represents  a  lower  forceps,  which  may  be  used  alike 
for  incisors  or  canines;  of  this  the  same  may  be  said  as  of  the 
pair  previously  described.] 


EXTRACTION    OF    TEETH.  277 

In  employing  the  forceps,  the  student  cannot  do  hetter  than 
follow  the  excellent  directions  laid  down  by  J.  Tomes,'  who 
divides  the  process  into  three  stages,  insisting  most  properly 
upon  eacli  being  [jcrfectly  accomplished  before  the  succeeding 
one  is  attempted.  The  stages  are — "first,  the  seizure  of  the 
tooth  ;  second,  the  destruction  of  its  mend)ranous  connection 
with  the  socket ;  third,  the  removal  of  the  tooth  from  the  socket." 

In  the  first  stage  the  instrument  sljonld  be  taken  lightly  in 
the  palm  of  the  hand,  the  blades  pointing  upwards  or  down- 
wards, according  to  the  jaw  operated  on,  the  thumb  being  em- 
ployed as  a  stop  or  regulator,  to  govern  the  amount  of  separa- 
tion of  the  handles  and  consequently  of  the  blades.  In  applying 
it  to  the  tooth,  it  is  well  first  to  adapt  one  blade  to  the  side 
most  obscured  from  the  view  of  the  operator,  and  then  to  close 
the  other  upon  the  opposite  side,  but  only  so  lightly  as  just  to 
touch  the  tooth  at  the  point  of  its  connection  with  the  gum. 
This  done,  the  thumb  is  now  gradually  withdrawn,  and  steady 
but  forcible  pressure  made  in  the  direction  of  the  root  of  the 
tooth.  The  force  employed  should  be  regulated  by  the  amount 
of  resistance  experienced,  commencing  gently  and  increasing  as 
the  case  demands,  and  often  accompanied  to  advantage  by  a 
very  slight  rotatory  movement  at  the  same  time.  Experience 
will  enable  the  operator  to  tell  when  this  has  been  accom- 
plished to  the  proper  extent,  but  we  fear  that  some  have  read 
too  literally  the  injunction,  to  "  push  the  jaws  of  your  forcejo 
into  the  socket,  as  though  you  intended  they  should  come 
out  at  the  top  of  the  head  or  under  the  chin,"  as  we  have 
seen  it  fulfilled  on  teeth  which  needed  no  such  roughness,  caus- 
ing unnecessary  pain.  The  operator  must  judge,  as  he  pro- 
gresses, how  much  force  is  required,  commencing  gently,  but 
continuing  to  increase  the  force  until  the  object  in  view,  viz., 
a  firm  grasp  of  the  tooth  at  or  above  its  neck,  as  the  state  or 
diseased  condition  may  indicate,  is  obtained.  Perhaps  more 
judgment  is  required  in  this  portion  of  the  operation  than  in 
any  other;  and  it  must  be  admitted  that,  if  it  be  unskilful  to 
use  unnecessary  force  in  it,  it  will  prove  more  unfortunate  to 
err  on  the  other  side,  and  cause  the  fracture  of  a  tooth  by  era- 
ploying  too  little.     The  tooth   being  grasped  at  the  right  spot, 

'  Lectures,  etc.,  p.  326. 


278    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

it  must  be  retained  by  a  force  sufficient  to  prevent  the  instru- 
ment from  slippinsj,  but  not  so  great  as  to  endanger  the  some- 
what fragile  object;  and  then  the  second  stage  of  the  operation, 
the  severing  of  it  more  or  less  from  its  membranous  attach- 
ment, is  commenced.  This  will  consist  in  either  a  slightly  ro- 
tatory movement  in  the  long  axis  of  the  tooth,  as  in  the  case  of 
one  having  a  conical  fang,  or  an  inward  and  outward  one,  %.  ?., 
between  the  adjoining  teeth  to  and  from  the  mesial  line  of  the 
dental  arch,  when  the  fang  is  not  conical,  or  there  are  more 
fangs  than  one.  In  making  these  movements,  we  should  follow 
certain  general  directions  to  be  presently  mentioned  ;  but,  if  we 
fail  with  moderate  force  to  cause  the  tooth  to  yield,  we  may 


© 


Fig.  245.  Fig.  246. 


/TT)  (5^         r^ 

Transverse  sections  of  the  teeth  of  the  upper  Transverse  sections  of  the  teeth  of  the  lower 

jaw  made  at  their  necks.  .iaw  made  at  their  necks. 

These  figures  will  be  fiequently  referred  to  in  the  present  chapter. 

employ  it  in  others,  gradually  increasing  it  as  we  find  our  efforts 
availing.  The  yielding  of  the  alveolo-dental  membrane  gives 
a  sensation  which  we  can  readily  perceive,  and,  when  it  is  suffi- 
ciently severed,  we  may  connect  with  our  movements  of  de- 
tachment those  more  truly  extractive,  the  third  stage  of  the 
operation.  Judgment  must  be  exercised  here  too;  for,  if  the 
extractive  force  be  put  on  too  soon,  fracture,  or  too  great  a 
resistance,  will  be  experienced  ;  if  put  on  too  late,  much  unne- 
cessary pain  is  inflicted  :  error  in  the  former  alternative  is  likely 
to  be  attended  with  the  unwelcome  exhibition  of  portions  of 
alveolar  process.  The  extractive  force  should,  as  a  rule,  be  ex- 
erted chiefly  in  the  direction  of  the  long  axis  of  the  tooth  ;  but 
it  is  a  rule  with   many  exceptions.     The  skilful  operator  will 


EXTRACTION    OF    TEETH, 


279 


jutlge  in  which  direction  the  loosened  tootli  is  coming  most 
readily,  and  in  the  direction  of  least  resistance  he  should  exert 
the  traction.  It  is  in  this  respect  that  the  forceps  is  so  superior 
to  the  key  or  other  instruments,  viz.,  in  its  enabling  the  ope- 
rator to  vary  the  direction  of  the  force  that  he  employs. 

Having  described  the  mode  of  applying  the  forceps  in  general, 
we  now  proceed  to  explain  its  application  in  the  case  of  individual 
teeth,  and  must,  in  so  doing,  take  it  for  granted  that  the  reader 
is  conversant  witii  dental  anatomy,  and  fully  acquainted  with 
the  forms  wliich  the  teeth  in  man  present.  He  must  know  that 
horizontal  sections  of  upper  incisors  and  cuspidati  (Fig.  245), 
made  at  or  a  little  below  their  necks,  present  at  the  divided  sur- 
faces an  almost  circular  form,  the  anterior  and  posterior  aspects 
of  which  will  be  arcs  of  a  circle — the  anterior  a  rather  larger 
one  than  the  posterior.  The  blades  of  the  forceps  must  be  con- 
structed to  correspond  to  such  forms,  and  to  cover,  when  applied, 
rather  more  than  a  third  of  the  surface  of  the  tooth  grasp)ed. 
In  the  perfect  instrument  the  inner  blade  should  represent  a  less 
obtuse  angle  with  the  inner  handle  than  the  outer  blade  does 
with  the  outer  handle,  in  accordance  wMth  the  form  presented 
by  the  roots  of  these  teeth  (Figs.  247,  248,  249).     Whilst  the 


Fio-.  247. 


Fia:.  248. 


Fiir.  249. 


Central  incisor  of  upper  jaw, 
front  and  side  views. 


Lateral  incisor  of  upper  jaw, 
front  and  side  views. 


Cuspidatus  of  upper  jaw, 
front  and  side  views. 


same  instrument  may  be  employed  for  all  the  above-mentioned 
teeth,  a  pair  with  narrower  blades  (Fig.  243)  may  be  desirable 
when  very  small  lateral  incisors  have  to  be  dealt  with.  The 
operation  of  extracting  these  teeth  is  thus  performed :  the  patient 
should  be  seated  and  facing  a  good  light,  and,  if  a  proper  dental 
chair  be  not  at  hand,  an  old-fashioned  easj^  one,  provided  with 
a  cushion,  to  raise  the  body  so  that  the  head  may  recline  steadily 
on  the  top  of  it,  will  answ^er  sufficiently  well.  If  such  a  chair 
be  not  procurable — for  these  operations  have  often  to  be  per- 


280   MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

formed  at  patients'  houses — the  following  may  be  adopted  :  The 
patient  is  seated  upon  an  ordinary  chair,  whilst  a  second  chair 
is  placed  at  the  back;  on  this  latter  the  operator  firmly  places 
his  left  foot,  and  covering  his  knee  with  a  towel,  makes  it  a  soft 
but  firm  support  for  the  patient's  head.  The  foregoing  sugges- 
tions are,  of  course,  available  also  with  all  the  teeth  of  the  upper 
jaw.  In  applying  the  forceps  to  the  teeth  in  question — upper 
incisors  or  cuspidati — the  operator  should  stand  rather  in  front, 
and  on  the  patient's  right  side  ;  with  the  thumb  of  the  left  hand 
the  lip  should  be  raised,  whilst  the  fingers  of  the  same  resting 
upon  the  patient's  forehead  afibrd  steadiness  to  both  patient  and 
operator:  if  preferred,  the  operator  may  apply  the  finger  and 
thumb  of  the  left  hand  to  each  side  of  the  alveolar  process  ad- 
joining the  tooth  ;  this  latter  has  the  advantage  of  affording 
some  knowledge  of  the  yielding  of  the  tooth  to  the  force  applied. 
[The  concave  portion  of  the  palm  of  the  left  hand  wmU  be  over 
the  cheek  and  the  prominence  made  by  the  zygomatic  arch. 
The  prominence  near  the  wrist  or  the  fingers  may  rest  lightly 
upon  the  orbital  process  or  temporal  region  of  the  head.]  The 
forceps,  held  as  before  directed,  should  be  applied  to  the  neck  of 
the  tooth,  to  its  posterior  surface  first,  and  then  closed  gently 
upon  it  by  the  thumb  being  withdrawn  :  the  instrument  is  now 
forced  upwards  in  the  direction  of  the  long  axis  of  the  tooth, 
until  tlje  edge  of  the  alveolus,  or,  if  the  tooth  be  much  decayed, 
a  point  beyond,  is  reached.  The  tooth  being  firmly  grasped,  a 
slight  rotation  in  one  direction  is  attempted  ;  but,  if  much  resist- 
ance be  encountered,  the  rotary  movement  is  reversed,  and,  if 
still  resisted,  it  may  be  exchanged  for  an  inward  and  outward 
one,  i.  e.,  to  and  from  the  centre  of  the  palate,  coupled  with  a 
return  to  the  rotary.  [Generally  the  rotary  movement  should 
be  very  slight  for  all  teeth  save  the  superior  central  incisors.] 
As  the  tooth  begins  to  yield  from  its  attachments,  the  force  may 
be  gradually  changed  to  a  doAvnward  one  in  the  direction  of  the 
long  axis  of  the  tooth,  but  it  should  be  steady  and  guarded,  in- 
clining to  the  direction  in  which  the  tooth  seems  the  most  willing 
to  yield.  It  is  not  elegant  or  agreeable  to  witness  the  tooth 
l^arting  from  its  socket  with  a  sudden  jerk,  although  it  not  un- 
frequently  shoots  from  it,  owing  to  its  sliding  along  the  double 
inclined  plane  formed  by  the  hlades  of  the  forceps ;  an  occurrence 
not  always  possible  to  avoid,  but  one  which  we  should  do  our 


EXTRACTION    OF    TEETH.  281 

utmost  to  prevent,  as  tlie  tooth  ma}'  disappear  into  the  throat 
or  even  larynx  under  such  circumstances.  More  force  will  be 
necessary  in  the  removal  of  the  cuspidati  than  in  that  of  the 
central  incisors,  and  more  in  the  case  of  the  latter  than  in  that 

Fitc.  350.  Fig.  251. 


Upper  first  bicuspid,  front  and  side  views.  Upper  second  bicuspid,  front  and  side  views. 

of  the  lateral  incisors,  [The  apices  of  the  roots  of  the  latter  teeth 
very  often  have  a  sharp  turn  or  crook,  which  will  be  broken  by 
a  hasty  movement  in  the  wrong  direction.  These  crooked  por- 
tions of  all  teeth  roots  that  curve  have  a  general  inclination 
away  from  the  mesial  line  toivard  the  distal  face,  requiring  the 
motion  to  be  backward,  or  such  as  to  unhook  it.]  We  now  pass 
on  to  the  bicuspids  of  the  upper  jaw,  sections  of  which  at  their 
necks  (Fig.  245)  are  of  a  less  circular  form  than  is  that  of  the 
teeth  just  considered,  which,  instead  of  having  an  almost  conical 
root,  have  a  somewhat  flattened  one  (Fig.  250),  the  teeth  being 
broadest  between  their  external  and  internal  surfaces.  In  the 
place  of  one  fjing  there  may  be  two  or  very  rarely  three,  this 
being  more  common  in  the  first  than  in  the  second  bicuspid 
(Figs.  250,  251),  although  some  works  on  anatomy  give  the  re- 
verse. For  these  teeth  we  must  have  an  instrument  (Fig.  243), 
the  blades  of  which  must  be  segments  of  the  circle  presented  by 
the  external  and  internal  surfaces  of  these  teeth  at  their  necks, 
and  for  all  practical  purposes  segments  of  the  same  circle  will 
suffice;  otherwise  we  should  require  a  pair  for  each  side  of  the 
mouth,  as  the  handles  are  bent  at  an  angle  with  the  blades,  to 
prevent  the  former  from  pressing  against  the  lower  lip  during 
the  operation.  The  breadth  of  the  blades  should  be  about  the 
same  as  in  the  instrument  for  the  central  incisors  and  cuspidati. 
The  operator  assuming  much  the  same  position  as  that  just 
described,  which  is  generally  best  suited  to  the  removal  of  all 
the  upper  teeth,  the  instrument  is  applied  and  forced  upwards, 
as  before  directed.     The  severing  movements  must  be  accom- 


282    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

plished  by  force  exerted  to  and  from  the  palate — we  prefer  it  in 
that  order  i.  <?.,  first  inwards  towards  the  palate,  followed  by  a 
more  forcible  one  in  the  opposite  direction,  rotation  in  the  case 
of  the  bicuspids  being  out  of  the  question  ;  their  flattened  fangs, 
and  the  circumstance  of  their  having  often  two  fangs,  would 
otter  great  resistance  to  such  movement.  As  the  tooth  yields 
the  extractive  force  may  be  commenced,  and  in  the  line  of  the 
long  axis  of  the  tooth,  or  varied, as  resistance  may  indicate;  and 
with  it  at  times  a  slight  shaking  movement  of  the  wrist  may  be 
advantageously  combined.  We  may  observe  that  in  removing 
these  teeth  to  afford  space  a  slower  and  more  gentle  action 
should,  if  possible,  be  adopted  ;  for,  while  a  small  fractured  por- 
tion of  a  healthy  fang,  when  left,  is  seldom  attended  with  un- 
pleasant consequences,  it  would  in  these  cases  much  retard,  if  not 
prevent,  adjacent  teeth  from  moving  into  the  space  thus  made. 

The  molars  of  the  upper  jaw  (Figs.  252,  253)  present,  on 
section  at  their  necks  (see  Fig.  245)  a  more  varied  figure  than 
the  foregoing,  viz.,  in  the  external  surface  being  segments  of 
two  circles  united  at  one  extremity,  of  which  the  anterior  is 

Fig.  252.  Fig.  253. 


First  molar  of  the  upper  jaw.  Secoiul  molar  of  tlie  upper  jaw. 

rather  the  larger,  whilst  the  internal  surface  represents  the 
segment  of  a  circle  much  larger  than  either.  In  conformity  with 
these  circles  must  be  the  blades  of  the  instrument  (Fig.  238), 
which  must  be  broader  and  somewhat  stronger  than  those 
already  considered,  as  should  be  the  instrument  generally;  it 
will  also  be  desirable  to  have  the  blades  at  a  greater  angle  with 
the  handles  than  in  that  last  described.  In  addition  to  this 
angle,  some  prefer  also  a  curve  in  the  handles,  as  shown  in  the 
figure,  the  bend  being  towards  the  roof  of  the  mouth  wdien  the 
instrument  is  employed.  It  is  a  matter  of  little  importance,  but 
in  our  opinion  rather  a  defect  than  otherwise,  as  in  practice  the 
straight  handles  aflford  a  better  grasp,  and  are  quite  as  conve- 
nient as  the  curved. 


EXTRACTION    OF    TEETH.  283 

In  removing  a  tooth  of  such  dimensions  and  resisting  form 
as  an  upper  molar,  we  must  be  prepared  to  exert  a  larger 
amount  of  force  than  upon  smaller  teeth,  and  tliis  especially 
in  grasping  them,  and  when  a  very  slight  lateral  movement 
accompanying  the  forcing  upwards  of  the  instrument  will  often 
prove  advantageous.  From  the  directions  of  tlie  fangs  we  at 
once  see  that  only  an  inward  and  outward  movement  is  feasible, 
and  the  rule  generally  given  to  commence  with  the  inward  one 
is,  we  believe,  correct :  it  is  not,  however,  to  be  persisted  in  until 
some  movement  is  effected,  for,  should  this  not  come  pretty 
readily,  then  the  outward  movement  is  to  be  adopted,  and  with 
this  a  moderate  amount  of  force,  exerted  also  in  tbe  downward 
direction,  often  efi'ects  the  complete  removal  of  the  tooth.  [The 
inner  plate  of  the  alveolar  process  is,  as  a  rule,  the  heavier,  and 
does  not  yield  as  readily  as  the  outer  one.]  Generally,  however, 
the  lateral  movements  may  have  to  be  repeated  before  the  truly 
extractive  ones  can  be  attempted.  It  must  here  be  remembered 
that  we  have,  besides  the  strong  membranous  attachments,  to 
overcome  the  dovetailing  of  the  roots  and  alveolus  ;  consequentlj' 
the  latter  must  be  dilated  in  most  cases;  fortunately  they  are, 
in  the  recent  state,  soft  and  moderately  yielding. 

[The  loosening  movement  should  be  continued  until  the  tooth 
seems  almost  enough  detached  to  be  taken  out  by  the  fingers. 
In  the  temple  of  Apollo,  at  Delphi,  it  is  said,  a  leaden  extractor 
was  exhibited,  to  teach  the  student  that  no  tooth  should  be  ex- 
tracted until  it  was  loose  enough  to  be  easily  removed.^] 

The  second   molar  may   be  removed  precisely  in  the  same 
manner,  and  with   the  same  instrument  as  the  lirst;  generally 
more  readily,  as  the  tooth  is  not  so  large, 
nor  its  fangs  so  divergent.     The  third  molar  Fig.  254. 

(Fig.  254)  of  the  same  jaw  has  the  two 
external  circles  at  its  neck  so  feebly  pro- 
nounced (Fig.  245),  that  an  instrument  (Fig. 
236),  both  blades  of  wdiich  are  segments  of 
one  large  circle,  will  be  found  better  ada[>ted 
than  the  form  suitable  for  the  first  and  sec-  Third  moiar  or  wisdom 
ond    molars;    consequently   such    an    instru-    tooth  of  t&e  upper  jaw. 

['  See  pp.  4  and  13,  "A  Practical  Guide  to  Operations  on  the  Teeth,"  by 
James  Suell,  Dentist  ;  Carey  &  Lea,  Phila. ,  1832.] 


284        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

ment  may  be  employed  for  eitlier  side,  whereas  for  the  latter  in- 
struments for  the  right  and  left  side  are  necessary.  The  liandles 
ought  to  form  a  considerable  angle  with  the  blades,  otherwise 
it  will  be  impossible  to  adjust  them  accurately,  and  in  the  di- 
rection of  the  vertical  axis  of  the  tooth.  Except  from  the  in- 
accessibility due  to  their  position,  the  third  upper  molars  are 
not,  as  a  rule,  very  difficult  to  remove ;  their  roots,  if  not  agglu- 
tinated, are  generally  but  slightly  divergent ;  and  the  bone  in 
which  they  are  placed  is  soft  and  spongy.  From  the  direction 
of  their  long  axes,  the  movements  of  detachment  and  removal 
may  be  combined  in  an  outward  and  downward  one  from  first 
to  last,  it  often  being  necessary  to  make  the  latter  considerable  ; 
indeed,  a  circle  passing  from  the  crowai  of  the  tooth,  downwards, 
outwards,  and  upwards  in  the  direction  of  the  zygomatic  pro- 
cess;  an  exaggerated  curve  corresponding  to  that  which  the 
fang  of  the  tooth  often  assumes  in  its  alveolus. 

AVhen  we  operate  upon  the  teeth  of  the  lower  jaw,  the  patient 
may  conveniently  be  seated  in  an  ordinary  easy  chair,  the  head 
being  in  a  line  with  the  body,  i.  e.,  in  the  usual  sitting  posture, 
or  nearly  so.  As  horizontal  sections  of  incisor  teeth  of  the 
lower  jaw  at  their  necks  represent  an  ovoid  figure,  flattened 
laterally  (see  Fig.  246),  the  anterior  and  posterior  surfaces  of 
which  are  segments  of  a  circle  much  smaller  than  that  presented 
by  the  upper  incisor  teeth,  the  blades  of  the  instrument  to  be 
employed  for  their  removal  must  be  narrower  and  arcs  of  a 
smaller  circle,  than  in  the  case  of  the  upper  incisors,  and  in  re- 
lation to  the  handles,  curved  as  in  Fig.  244.  In  employing  the 
instrument,  the  operator  may  stand  on  the  right  of  the  patient, 
steadying  the  lower  jaw  with  the  fingers  of  the  left  hand,  whilst 
the  thumb  depresses  [the  tongue,  and  the  index  finger]  the  lower 
lip,  rendering  clear  to  view  the  teeth  upon  which  he  is  lookijjg 
down.  The  instrument  being  well  pressed  down,  tlie  severing 
or  detaching  movements,  which  can  only  be  inward  and  out- 
ward in  direction,  must  be  very  cautiously  performed,  as  the 
fangs  of  these  teeth  are  very  slight  (Figs.  255,  256,  257),  and 
consequently  easily  fractured  ;  they  will  be  found  to  yield  most 
readily  in  the  outward  direction,  in  which,  combined  with  an 
upward  direction  also,  the  final  extractive  force  should  be  ex- 
erted. 


EXTRACTION    OF    TEETH. 


285 


For  the  lower  cuspidati  not  only  should  the  blades  of  the 
instrument  be  somewhat  broader,  but  they  should  represent 
segments  of  a  larger  circle;  still  in  practice  the  same  as  that 
suitable  for  the  incisors   is  found  to  answer  very  well.     The 


Fi":.  255. 


Fiff.  256. 


Fi-.  257. 


Central  incisor  of  the 
lower  jaw,  frontand  side 
views. 


Lateral  incisor  of  the 
lower  jaw,  front  and 
side  views. 


Cuspidatas  of  the  lower  jaw, 
front  and  side  views. 


severing  movements,  as  suggested  from  a  lateral  view  of  their 
roots  (Fig.  '257),  must  be  in  the  same  directions,  viz.,  to  and  from 
the  centre  of  the  dental  arch,  but  they  will  require  more  force 
in  their  removal  than  the  incisors  usually  do.  [This  motion 
should  be  generally  toward  a  point  re[»resenting  the  centre  of 
the  arc  in  which  the  teeth  are  arranged,  or,  in  other  w^ords,  in 
and  out  on  a  line  corresponding  to  the  radius  of  the  curve  which 
is  formed  by  the  teeth.]  In  removing  the  tooth  of  the  left  side, 
the  operator  should  stand  almost  in  front  of  the  patient,  or  the 
patient's  head  should  be  turned  towards  the  operator. 

For  the  bicuspids  of  the  lower  jaw  (Figs.  258,  259)  we  shall 


Fi-.  258. 


Fin;.  259. 


First  bicuspid  of  the  lower  jaw,  front 
and  side  views. 


Second  bicuspid  of  the  lower  jaw, 
front  and  side  views. 


best  employ  an  instrument  differing  little  from  that  last  de- 
scribed, except  that  [it  may  be  slightly  heavier] ;  these  must  be 
employed  more  from  the  front  of  the  mouth. 

In  operating  with  the  straight  forceps  on  the  right  side  of  the 
mouth,  the  best  position  is,  to  stand  almost  in  front  of  the  patient 


286   MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

whilst  for  the  left  side  we  should  recommend  a  position  at  the 
back  of  the  patient,  bending  over  towards  his  head,  but  in  both 
cases  employing  the  finger  and  thumb  of  the  left  hand  for  sepa- 
rating the  lips  and  tongue  from  the  gums,  in  order  to  enable 
him  to  see  clearly  where  to  apply  the  instrument,  and  avoid  in- 
cluding in  it  a  fold  of  the  loose  mucous  membrane  which  forms 
the  floor  of  the  mouth.     It  may  be  carefully  noted,  that  sections 
of  lower  bicuspid  teeth  at  their  necks  (see  Fig.  246)  present  an 
almost  circular  form,  and  that  their  roots  generally  are  conical. 
The  forceps  should  be  firmlj'^  pressed  vertically  downwards  in 
the  direction  of  the  tooth,  and  the  severing  process  attempted 
by  a  slight  rotatory  movement,  first  in  one  direction  and  then 
in  the  opposite;  but  it  often  happens  that  detachment  is  felt  at 
the  first  movement,  and  then  force  applied  in  a  direction  up- 
wards and  a  little  outwards  will  remove  the  tooth.     The  lower 
bicuspids  are,  however,  very  uncertain  teeth  to  deal  with  ;  occa- 
sionally parting  from  their  surroundings  with  but  little  persua- 
sion, yet  at  times  presenting  very  great   resistance;  we  must, 
therefore,  apply  our  rotatory  force  with  discretion,  changing  it 
for  an  inward  and  outward  one,  or  even  combining  the  two, 
rather  than  risk  a  force  greater  than  that  which  holds  the  parti- 
cles of  a  tooth  to  each  other,  viz.,  its  cohesive  attraction.     The 
roots  of  these  teeth,  normally  conical  in  form,  and  eminently 
suitable  for  the  rotatory  movement,^  are  very  liable  to  be  curved 
or  twisted,  or  to  have  enlargements  at  their  extremities,  thus 
opposing  obstacles  to  such  and  other  movements  for  their  detach- 
ment;  and  very  often  also,  when  they  are  detached  from  their 
immediate    surroundings,  they    are   yet   dovetailed  into  their 
alveoli,  from  which  they  may,  if  care  be  not  exercised,  come 
away  very  suddenly,  causing  the  instrument  to  strike  against, 
and,  perhaps,  damage  the  teeth  of  the  upper  jaw ;  but  this  is 
more  liable  to  occur  in  the  extraction  of  the  teeth  which  we 
next  consider — the  lower  molars.    For  the  first  and  second  molars 
(Figs.  260  and  261)  the  position  of  the  operator  in  regard  to  the 
patient  will  be  much  the  same  as  in  the  case  of  the   teeth  last 
mentioned. 

'  It  should  be  distinctly  borne  in  mind,  that  the  bicuspids  are  the  only  teeth 
of  the  lower  jaw  to  which  a  rotator    movement  in  extraction  is  admissible. 


EXTRACTION    OF    TEETH. 


287 


A  horizontal  section  of  a  lower  molar  tooth  at  the  neck  (Fig. 
246)  shows  hoth  its  external  and  internal  surfaces,  of  much  the 
same  form  as  the  external  surface  of  the  first  upper  molar,  viz., 
two  segments  of  circles  touching  each  other  at  one  extremity, 
of  which  the  anterior  segment  is  the  larger.  The  blades  of  the 
instruments  must,  therefore,  be  made  to  correspond  in  like 
manner;  and,  in  order  to  insure  the  greatest  accuracy,  there 
should  be  an  instrument  for  each  side  of  the  mouth  ;  practically, 
however,  the  difference  between  the  sides  of  the  tooth  is  so  small 


Fig.  260. 


First  molar  of  the  lower  jaw. 


Fiff.  261. 


Second  molar  of  the  lower  jaw. 


that  one  instrument  may  suffice  (except  in  the  case  of  the  addi- 
tional curve  spoken  of),  provided  the  hinge  possesses  a  little  play. 
It  is  essential,  too,  that  the  angle  between  the  blades  and  handles 
should  be  nearly  a  right  angle.  In  using  these  forceps,  the 
operator  should  stand  in  the  same  positions  as  those  recommended 
in  the  case  of  the  bicuspids,  and  employing  the  left  hand  in  the 
same  manner;  but  he  may  with  advantage,  in  employing  the 
instruments  applied  at  the  front  of  the  mouth,  after  separating 
the  lips  and  tongue  from  the  gum,  and  placing  the  forceps  on 
the  tooth,  place  the  fingers  under  the  chin  to  support  the  jaw, 
and  employ  the  thumb  to  press  the  forceps  well  down.  Slight 
inward  movement  may  first  be  attempted,  but  the  tooth  will 
generally  yield  most  readily  in  the  outward  direction,  where  the 
alveolus  is  less  thick;  ajid,  in  raising  the  tooth,  it  wnll  also  be 
found  to  come  most  readily  in  the  same  direction.  The  two 
large  and  dense  fangs  (Fig.  260),  anterior  and  posterior,  especi- 
ally of  first  lower  molars,  often  occupy  more  space  than  does  the 
tooth  at  its  crown,  where  it  is  in  contact  with  its  neighbors.  To 
raise  it  vertically,  without  injury  to  the  latter,  would  be  impos- 
sible :  and,  where  the  fangs  spread  to  any  extent,  the  tooth  be- 
comes locked,  and  then  it  is  necessarj'  to  continue  for  some  time 


288    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

the  lateral  movements  in  order  to  dilate  the  alveolus,  varying 
them  with  extractive  force  in  a  direction  considerably  outwards, 
but  taking  evevy  care  that  the  instrument  in  coming  upwards 
does  not  strike  and  injure  the  upper  teeth:  the  left  thumb,  in 
such  cases,  may  be  well  retained  on  the  upper  part  of  the  for- 
ceps. A  pinch  of  the  thumb  may  result,  but  the  operator  will 
smart  less  from  this  than  if  he  fractured  his  patient's  sound 
tooth. 

For  a  tooth  which  happens  to  be  locked  in  the  manner  above 
mentioned,  the  lateral  movements  are  no  doiibt  best  performed 
by  the  instruments  which  are  applied  from  the  front  of  the 
mouth. 

On  comparing  a  horizontal  section  of  a  lower  third  molar, 
made  at  the  neck  (see  Fig.  246),  with  a  similar  one  in  a  first  or 
second  molar,  it  will  be  observed  that  the  depressions  on  each 
side  marking  the  union  of  the  two  fangs  are  much  less  distinct. 
In  making  the  lateral  severing  movements,  we  shall  generally 
experience  great  resistance,  the  cause  of  which  will  be  evident 
if  we  examine  such  a  tooth  in  situ,  by  removing  the  external 
alveolar  plate  of  the  maxilla.  When  it  is  thus  exposed,  it  will 
be  noticed  that  the  fangs  incline  backwards  (Fig.  262),  i.  e., 
towards  the  angle  of  the  jaw,  a  curving  wdiich 
Fig.  262,  is  seen  to  increase  from  the  first  to  the  third 

molar  tooth;  the  greater  such  curve  is,  the 
greater  obviously  will  be  the  resistance  to  lateral 
movement,  as  a  larger  surface  is  impinged  upon. 
The  form  of  the  curve  also  indicates  the  direc- 
tion in  which  such  a  tooth  will  most  readily 
yield   to  force,  viz.,  upwards  and   backwards. 

Third  molar  of  the        "^  '■  ci        i 

lower  jaw  right  side,  towards  ths  coronoid  proccsscs.  buch  a  move- 
it  will  be  observed     ^^^^^^  -^  ^g  almost  impossiblc  to  effect  with  the 

how  much  the  fangs  ^ 

incline  in  the  direc-  forccps,  but  it  is  tlic  prccisc  oue  which  an  in- 
tion  of  the  coronoid     gti-uniciit,  virtually  one-half  of  a  pair  of  forceps 

process  of  the  jaw.  '  ■'  _       ■"•  .      / 

— the  elevator — can  readily  effect;  and  this  in- 
strument, which  we  shall  presently  describe,  we  recommend  for 
removing  third  molars,  especially  when  the  second  molars  re- 
main in  situ. 

[The  cutting  forceps  (Fig.  237)  may  be  used  to  divide  the  roots 
60  that  tiiey  may  be  separately  removed,  es[)ecially  if  they  should 


EXTRACTION    OF    TEETH. 


289 


curve  toward  each  other,  cnibraciiii-;  as  they  oi'ten  do  a  portion 

of  the  bone,  whicli  otherwise  would  require  to  be  broken  ott*  in 

the  removal  of  tlie  tooth. 

The  same  force]is  miiy  be  uned  as  elevators  as  described  before.] 
AVe  have   endeavored  to  tiibulate  tlie  foregoing  instructions, 

as  we  ho[ie  by  so  doing  to  make  them  more  available  to  the 

student. 

Teeth  of  Upper  Jaw. 

Patient  seated  raised  and  with  head  resting  backwards  [and  tnrned  to  the  left 
for  extraction  of  teeth  from  the  right  side  of  the  mouth]. 


Teeth. 

F<angs. 

Forceps. 

Detaching  move- 
nients. 

Operator. 

Inc   and 

1  conical 

Figs.  231 

Slight  rotation 

On   right   side    and 

cusp. 

and  243 

rather  in  front  of  P. 

Bicuspids 

1  or  2  flattened 

Figs.  231 

Inwards    and 

Do. 

laterally 

and  23r) 

outwards 

Molars,  1st 

3,  2  external  and 

Figs.  233 

Do. 

Do. 

and  2d 

1  internal 

and  240 

Molars,  3d 

Do.  often  agglu- 
tinated 

Figs.  23G 
and  242 

Do. 

Do. 

Teeth  of  Lower  Jaw. 

Patient  seated  at  ordinary  height,  head  in  vertical  position  [and  turned  to  the 
left  for  extraction  of  teeth  from  the  right  side  of  the  mouth]. 


Teeth. 

Fangs. 

Forceps. 

Detaching  inove- 
lueuts. 

Operator. 

Inc.  and 

1  flattened  late- 

Figs.  232 

Inwards   and 

To  the  right  of  P. 

cusp. 

rallj^ 

and  244 

outwards 

Bicuspids 

1  conical 

Do. 

Slight  rotation 

Do.  for   right    side, 
for  left  side  in  front 
to  right  of  P. 

Molars,  1st 

2,  1  ant.  and  1 

Figs.  234 

Inwards   and 

In   front  of  and   to 

and  2d 

post. 

and  241 

outwards 

the  right  of  P. 

Molars,  3d 

Do.  often  agglu- 

Figs. 234 

Do. 

Do. 

tinated. 

and  237 

19 


290    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY, 


CHAPTER  XIV. 

EXTRACTIOX  OF  ROOTS  OF  TEETH. 

Thus  far  we  have  taken  it  for  granted  that  the  teeth  on  which 
we  have  been  operating  are  fairly  strong  ones,  not  diseased  or 
injured  much  below  the  level  of  the  gums,  "When  teeth  in  the 
latter  condition  present  themselves,  our  instruments,  as  well  as 
our  line  of  operation,  must  be  somewhat  modified.  The  instru- 
ments must  for  such  conditions  have  their  blades  slighter,  also 
more  pointed  and  sharper  at  their  extremities,  to  enable  them  to 
obtain  a  secure  hold,  and  to  readily  divide  much  of  the  mem- 
branous attachments,  and  penetrate  into  the  alveoli,  often  to  a 
considerable  distance.  As  regards  the  remainder  of  the  instru- 
ments, handles,  hinges,  etc.,  they  ma}^  be  of  much  the  same 
construction  as  those  for  sound  teeth,  and  the  directions  already 
given  in  regard  to  position  of  patient,  operator,  etc.,  are  also 
applicable  to  tliem  ;  but  in  making  the  severing  movements  we 
shall  do  well  to  exert  the  force  more  gently  and  more  cautiously, 
preferring  to  lessen  the  danger  of  fracture  by  occupying  a  longer 
time:  in  the  extractive  movements  also  the  same  considerations 
should  influence  us. 

For  the  roots  of  upper  incisors  and  cuspidati,  instruments 
like  those  described  for  those  teeth,  but  having  thinner,  sharper, 
and  more  pointed  blades, are  used  (Figs.  235,  239).  In  pressing 
them  up  care  must  be  exercised  that  they  are  neither  too  widely 
open  nor  too  closely  shut:  the  latter  is  the  error  generally  made 
by  a  beginner,  especially  when  there  is  no  portion  of  the  tooth 
visiljle  above  the  gum,  or  only  a  portion  of  one  side  of  it  left  to 
guide  him,  when  the  instrument  becomes  forced  upon  the  root 
itself.  The  right  direction  being  ascertained  or  allowed  for — 
and,  if  a  knowledge  of  dental  anatomy  be  essential  to  insure  a  good 
extractorof  teeth,  it  becomes  of  imperative  necessity  when  hidden 
roots  are  o[)erated  u[)on — the  instrument  is  forced  upwards  in 
the  direction  of  the  long  axis  of  the  root,  this  being  often  much 


EXTRACTION  OF  ROOTS  OF  TEETH.  291 

assisted  by  a  slight  rotatory  movement  of  the  wrist  as  well  ; 
the  amount  of  pressure  necessary  will  be  determined  by  the 
resistance  to  it,  and  the  extent  to  which  the  disease  has  advanced. 
At  times  we  tind  the  roots  of  these  teeth  so  hollowed  out,  that 
but  little  more  than  tlicir  cemental  covering  remains  ;  and,  as 
such  fragile  tubes  must  of  necessity  collapse  upon  the  slightest 
pressure,  we  shall  do  well  to  fill  them  previously  with  gutta- 
percha, or  the  oxj'chloride  compound,  which  soon  sets,  and  will 
render  them  somewhat  solid  ;  or  we  may  employ  the  instrument 
(Fig.  -76),  which  consists  of  a  conical  screw.  This  is  inserted 
into  the  hollow  cavity  in  the  fang  until  firnilj^  held  in  position. 
Having  secured  a  good  hold,  with  very  cautious  grasp,  we  must 
proceed  gently  to  make  the  same  rotatory,  or  other  severing 
movements  [taking  care  that  they  are  made  to  the  right  always 
with  this  instrument  to  tighten  the  screw],  followed  hy  extractive- 
ones. 

The  roots  of  upper  bicusi»ids  require  blades  possessing  the  same 
characters  as  for  those  of  incisors  and  cuspidati  (Fig.  235),  and 
the  operation  of  their  removal  will  be  performed  with  the  same 
precautions.  It  must  be  borne  in  mind  that  these  teeth  have 
often  two  slender  roots,  especially  the  first  bicuspids,  and  their 
divergence  aftbrds  a  less  perfect  grasp  than  in  the  case  of  a  single 
and  more  conical  one ;  also  that,  when  the  tooth  is  grasped,  the 
two  roots  often  become  detached,  and,  moving  one  upon  the 
other,  cause  the  instrument  to  slide  off  them,  A  fine,  long- 
pointed  pair  of  forceps  (Fig.  239)  may  here  successfully  remove 
each  root  separately. 

Our  greatest  difficulties  will  perhaps  be  encountered  in  at- 
tempting the  removal  of  upper  molar  roots,  when  the  teeth  are 
broken  to  the  neck,  but  have  the  fangs  still  firmly  united  to  the 
remains  of  the  crown.  Such  a  root  roughly  represents  an  in- 
verted truncated  cone,  and  the  root-forceps  which  we  have  as  yet 
described  represents,  when  applied,  another  truncated  cone,  but 
not  inverted.  These  can  never  be  adapted  to  each  other,  they 
will  only  touch  at  points,  and  the  forceps  will  be  found  incapa- 
ble of  moving  the  tooth.  With  the  exception  of  instruments 
which  cut  bodily  through  the  external  alveolar  wall  and  thus 
admitted  a  grasp  of  the  tooth  above  its  neck,  those  similar  to 
Fig.  285  (page  272)  were  the  only  forceps  employed  for  the 
removal  of  such  roots  at  or  near  the  period  when  we  entered 


292        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

upon  practice;  and,  to  stipply  this  want,  we  constructed  some 
specially  adapted  to  the  conditions  in  question.  The  outer  blade 
(Figs.  263,204)  is  made  like  that  for  an  ordinary  molar  tooth, 

Fi<r.  263. 


Prof.  Coleman's  forceps,  dpsigncd  for  the  removal  of  upper  fir.stantl  second  molar  roots 
when  not  separated  from  the  crowD. 


Fig.  264. 


Represents  the  forceps  described  in  Fifj.  263  applied  to  a  molar  root. 

but  narrower,  rather  longer,  and  with  the  inter-circle  point  more 
pronounced  and  sharper:  the  inner  blade  is  also  narrower,  thinner, 
longer,  and  sharper,  and,  near  its  extremity,  bent  outward  in 
the  direction  which  the  palatine  fang  takes.     Such  an  instru- 
ment can  be  pressed  up  parallel  with  such  a  root,  and,  when 
closed  upon  it  will  insure  a  firm  grasp  at  or  between  tlie  two 
external  fangs,  as  well  as  upon  the  palatine  fang.     In  operating, 
the  force  should  be  perhaps  most  inclined  inwards,  as  there  is  some 
liability  of  the   instrument  slip[)ing  off  the  tooth  when  it  is 
moved  in  the  opposite  direction.     If    tlie  fangs  be  not  firmly 
united  to  the  crown,  the   instrument  will    then  divide  them, 
generally  bringing  away  one  or  more  of  them,  and  doing  the 
work  of  cutting-forceps  designed  es[iecially  for  the  separati(m 
of  such  roots.     These  latter  lorcejis  have  their  inner  or  palatine 
blade  of  much  the  same  form  as  in  those  last  described,  whilst 
the  outer  or  buccal  blade  terminates  in  a  vertical  cutting  edge 
(Fig.  265),  which,  when  closed,  approaches  within  a  short  dis- 
tance of  the  former.     In  the  ajjplication  of  them,  the  palatine 
])lade  is  first  adjusted  and  then  the  outer  closed  upon  it ;  generally, 
but  not  always,  in  such  application  dividing  a  portion  of  the 


EXTRACTION  OF  ROOTS  OF  TEETH, 


293 


mucous  nionibi'iine  and  the  thin  oulor  edge  of  the  alveolar  pro- 
cess.    Increased  pressure  cuts  tiirough  the  two  external  roots, 


Fi>'.  265. 


Forceps  for  separatiii!,'  the  fantrs  of  upper  molar  tfoth.     Ttu-  ('uttiIlg-^■(l^'.!  lila.l.-  is  applied  between 
the  two  esterual  faiiys,  tlie  opposite  bhule  to  the  palatiue  fangs. 

the  sharp  blade    penetrating  into  the  palatine  root,  which  is 
generally  brought  away  in  the  forceps,  and  the  operation  con- 

Fie;.  2GG. 


Forceps  (Stevens)  for  extracting  the  roots  of  upper  molars.  The  palatine  blade  is  divided  into 
two  points  which  grasp  the  palatine  root  on  cither  side  and  prevent  the  instrument  from  slipping 
of}' the  tooth. 

FisT.  2G7. 


Forceps  (Baly's)for  extracting  the  roots  of  upper  molars.    This  is  very  similar  in  con-itniction  to 
the  dividing  forceps,  but  by  means  of  the  stop  can  bo  employed  for  removing  the  fang  tn  masse. 


eluded  by  removing  the  separated  external  roots  with  fine  fang- 
forceps. 

That  such  roots  have  proved  a  difficulty  to  practitioners  is 


294    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

evidenced  bj-  the  variety  of  instruments  that  have  been  devised 
for  their  removal  (Figs.  266,  267).  When,  however,  the  dis- 
ease has  advanced  so  i'ar  as  to  have  destroyed  tlie  whole  of  the 
crown,  and  to  leave  the  several  roots  detached  from  each  other, 
the  operation  is  generally  a  simple  one,  and  readily  accomplished 
with  the  tine  root-forceps  (Fig.  235),  and  by  giving  to  the  in- 
strument a  rotatory  movement,  as  each  fang  separately  is  of  a 
conical  form.  The  roots  of  upper  third  molars,  not  generally 
divergent  to  the  extent  of  first  or  second  molars,  are  not,  except 

Fig.  268. 


Coleman's  forceps  for  extracting  the  roots  of  upper  third  molars. 

from  their  position,  very  difficult  to  remove.  Root-forceps,  the 
blades  of  which  when  open  are  nearly  parallel  with  each  other, 
and  wider  than  for  bicuspids,  and  are  at  a  much  greater  angle 
with  the  handles  (Fig.  268),  the  latter  inclining  backwards  at 
about  one  inch  from  the  hinge,  have  been  constructed  for  us, 
and  have  proved  of  great  service  for  many  years. 

The  same  forceps  may  often  be  employed  with  advantage 
for  other  molars  when  the  tooth  is  softened  to  tlie  bifurcation 
of  its  fangs:  for,  when  firmly  thrust  up  the  alveolus,  it  sel- 
dom fails  to  bring  away  one,  two,  or  sometimes  all,  the  roots  at 
once. 

Roots  of  lower  incisors  and  cuspidati  may  be  advantageously 
oiierated  upon  with  forceps  having  the  form  described  for  re- 
moving the  bicuspids  (Fig.  232),  but  provided  with  sligiiter 
and  sharper  pointed  blades  (Fig.  244).  For  the  incisors  they 
must  not  be  so  broad  as  to  impinge  upon  adjoining  teeth;  for 
the  bicuspids  we  may  use  the  same;  the  movements  will  be  the 
same  for  the  roots  as  for  the  teeth  themselves,  with  the  precau- 
tions given  with  regard  to  roots  generally.  For  either  of  the 
foregoing  we  may  also  employ  the  instrument  figured  (Fig.  237)- 
Roots  of  lower  maj*,  like  those  of  upper  molars,  be  found  de- 
tached or  united  to  their  crowns;  and  forceps  have  been  con- 
structed for  dividing  them,  or  sjtecially  acting  upon  them  (Figs. 
237,  241,  and  260)  in  this  condition.     These  we  have  found  un- 


EXTRACTION  OF  ROOTS  OF  TEETH 


295 


necessary,  because,  nccoi'diiiij^  to  our  experience,  tlioso  just  de- 
scribed accom[»lislied  the  object  more  perfectly.  If  we  take  the 
case  where  the  roots  are  connected  with  the  crown;  we  prefer 
root-forceps  used  from  the  side  of  the  mouth,  as  just  described, 


Fiar.  369. 


Forceps  for  extracting  the  roots  of  lower  molar  teeth  when  attached  to  the  crowns. 

and  apply  tbem  in  the  direction  of  one  of  the  fangs,  the  most 
visible  being  by  preference  selected.  The  ordinary  movements  for 
these  teetii  will  generallj^  bring  away  the  two  fangs,  but  it  may 
be  one  only,  and  then  the  other  is  in  like  manner  removed. 
Care,  however,  must  be  taken  to  apply  the  instrument  directly 
to  the  fang  and  not  to  the  space  between  the  two  fangs.  When 
these  are  separated,  the  matter  is  generally  simple  enough. 

The  elevator  we  have  already  compared  to  one-half  of  a  for- 
ceps, but  perhaps  it  would  be  more  correct  to  call  the  latter  a 
double  elevator,  as  the  obstetric  forceps  is  a  double  vectis  ;  and 
no  doubt  many  practitioners  employed  one  blade  of  the  forceps 
in  the  manner  of  an  elevator,  and  some  even  employed  the  sin- 
gle blade  detached,  previously  to  the  introduction  of  the  instru- 
ment described  and  figured  by  Bell  in  his  work,  to  whom  must 
be  accredited  its  parentage. 

Fi'j;.  270. 


George's  elevator,  front  and  side  view,  the  best  for  general  purposes. 

The  elevator,  for  the  term  punch  can  in  no  way  be  considered 
as  applical)le  to  it,  consists  essentially  of  two  portions  (Fig.  270), 
viz.,  the  blade  and  the  handle,  yet  in  all  forms  of  it  a  portion 


296    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

exists  which  is  iiiterraediate  between  the  two,  and  may  be  either 
straight  or  curved.  The  bhxde  is  that  portion  which,  as  in  the 
case  of  the  forceps,  is  applied  to  the  tooth,  and  some  forms  are 
constructed  as  if  with  the  intention  of  fitting  a  root  in  its  long 
diameter  (Fig.  271) ;  but,  as  the  elevator  is  rarel}^,  if  ever,  ap- 
plied in  such  a  direction,  the  cup-like  form  which  it  sometimes 
presents  is  only  a  barrier  to  its  eftective  employment.  The 
blade  should  be  thin,  about  one-fifth  of  an  inch  in  breadth 
(though  smaller  sizes  will  be  vevy  serviceable),  flat,  or  but 
slightl}'  concave  on  its  anterior  surface,  and  convexly  rounded 


Fiff.  271 


Tomes's  elevator,  witli  a  spuon-shaped  blade. 

on  its  posterior  surface,  and  from  tlie  latter  to  the  former  bevel- 
led off,  and  sharpened  to  a  Y-shaped  point:  the  anterior  sur- 
face may  with  advantage  be  finely  grooved  in  its  long  axis,^ 
the  posterior  quite  smooth,  and  the  extremity  kept  quite  sharp. 

The  handle  should  be  fullj^  four  inches  in  length,  roughened, 
and  of  sufficient  width  to  aftbrd  a  very  firm  grasp.  It  may  be 
eitlier  of  metal,  wood,  or  ivory  ;  the  latter  two  are  preferable, 
as  being  lighter. 

In  explaining  its  action  we  shall,  not  to  mince  matters,  call 
a  "spade  a  spade,"  and,  as  roots  of  plants  are  dug  out  of  the 
ground  by  that  instrument,  so  precisely  are  teeth  raised  from 
their  sockets  by  the  elevator,  notwithstanding  that  the  process 
in  the  latter  has  been  dignified  by  a  higher  title. 

It  is  not  so  easy  an  instrument  to  employ  as  the  forceps,  and 
certainly  requires  much  more  care  and  precaution  ;  it  may  easily 
slip,  and  cases  of  punctured  cheeks  and  tongues  are  unfortu- 
nately on  record.  Such  accidents,  however,  can  hardly  occur 
in  the  hands  of  the  experienced  and  well  trained.  Certain 
members  of  tlie  profession  have  for  many  years  been  celebrated 
for  their  skill  in  tlie  use  of  the  elevator,  and  amongst  these  the 
name  of  Cartwright  has  in  the  mouths  of  practitioners  been  a 
household  word.    It  was  our  privilege  to  be  associated  for  many 

'  We  believe  that  this  was  first  suggested  by  Salter. 


EXTRACTION  OF  ROOTS  OF  TEETH.  297 

years  with  a  member  of  that  family,  and  we  cannot  feel  too 
ifrateful  for  havinsc  so  often  witnessed  this  most  valuable  instru- 
ment  employer!  with  consummate  skill. 

AVhen  the  elevator  is  applied,  it  should  be  firmly  grasped  at 
the  handle,  and  held  much  like  the  knife  at  dinner,  the  fore- 
fiiiijer  of  the  rig-ht  liand  resting  upon  it  about  half  an  inch  from 
the  extremity  of  the  blade  ;  this  not  only  gives  steadiness,  but 
also  acts  as  a  stop  or  guard  should  the  instrument  happen  to 
slip.  The  forefinger  should  as  a  rule  be  applied  to  the  back  of 
the  elevator  in  an  operation  on  teeth  of  the  upper  jaw  and  right 
side  of  the  lower  jaw,  but  to  the  front  of  it  in  an  operation  on 
teeth  of  the  left  side  of  the  loAver  jaw  ;  this  is  on  the  assumption 
tliat  in  each  case  we  are  applying  the  elevator  to  the  anterior  sur- 
face of  the  tooth.  [The  index  finger  of  the  right  hand,  protected 
by  a  few  folds  of  napkin  and  held  on  the  opposite  side  of  the 
tooth,  will  often  do  good  service  in  preventing  injury  to  the  soft 
tissues  of  the  mouth  from  slipping  of  the  instrument  or  sudden 
movement  of  the  tooth.  This  finger  in  like  manner  serves  to 
}»revent  the  tooth  from  being  drop)ped  into  the  throat,  a  par- 
ticularly dangerous  accident  when  the  patient  is  unconscious 
from  an  anaesthetic.]  For  illustration,  let  us  suppose  that  we 
are  about  to  operate  on  a  third  molar  of  the  right  side  of  the 
lower  jaw,  extensively  decayed  upon  its  buccal  surface.  The 
elevator  being  held  as  before  described,  the  operator,  standing 
somewhat  behind  and  leaning  over  the  patient's  head,  and  sepa- 
rating, with  the  finger  and  thumb  of  the  left  hand,  the  tongue 
and  cheek  from  the  jaw,  should  introduce  the  point  of  the  in- 
etrument  at  the  margin  of  the  gum  and  at  the  interstice  between 
the  necks  of  the  second  and  third  molars  ;  and  the  point  should 
incline  towards  the  root  of  the  latter  rather  than  the  former, 
and  in  relation  to  its  alveolus  the  liandle  should  point  upwards, 
forwards,  and  a  little  outwards.  The  gum  must  be  penetrated 
in  inserting  the  blade,  and  its  introduction  into  the  alveolus 
w'ill  he  facilitated  by  giving  to  the  instrument  a  very  slight 
rotatory  movement,  an  increased  amount  of  which  will  doubtless 
have  the  effect  to  some  extent  of  loosening  the  tooth  ;  this 
movement  combined  with  an  upward  one,  effected  by  depressing 
the  handle,  will  generallj'  raise  the  tooth  from  its  socket,  and  in 
the  curve  before  mentioned,  viz.,  that  of  which  its  crown  and 
fangs  form  a  segment.     In  the  final  stage  of  the  operation  the 


298    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

force  must  be  exerted  almost  dlrectlj'  U[i\vards,  and  here  every 
care  must  be  taken  to  prevent  the  instrument  from  darting 
backwards,  wlien  resistance  is  no  longer  offered.  In  the  case  of 
lower  third  molars,  it  not  unfrequentl}^  happens,  that,  when 
elevated  from  their  sockets,  thej^  remain  attached  to  the  mucous 
membrane  which  is  firmly  adherent  to  their  necks  at  their  pos- 
terior surfaces,  from  which  tliey  must  afterwards  be  detached  by 
a  sickle  or  hoe-sha})ed  lancet,  or  scissors  having  curved  blades 
(Fig.  272).    The  elevator  is  employed  in  much  the  same  manner 

Fig.  273. 


A  pair  of  scissors  with  the  blades  at  an  angle  to  the  handles,  suitable  for  separating  a 
lower  wisdom  tooth  from  mucous  attachments  after  extraction. 


for  the  other  teeth,  except  that  in  the  upper  jaw,  and  especially 
for  the  roots  of  single  fang  teeth,  it  must  be  introduced  in  a 
more  vertical  direction. 

[Lancing  before  commencing  the  operation  is  only  desirable 
in  teeth  that  stand  alone,  to  avoid  tearing  the  soft  tissues.  The 
latter  are  often  attached  to  the  wisdom  teeth.  But  when  an 
anaesthetic  is  used,  it  may  be  as  well  to  leave  the  attachment  to 
act  as  a  safeguard  against  the  tooth  being  swallowed  or  drawn 
into  the  glottis.     It  may  then  be  severed  as  above.] 

For  detached  roots  of  both  jaws,  elevators  having  the  blades 
at  an  angle  to  the  handles  may  often  be  em[)loyed  with  great 
advantage  (Figs.  273,  274).  The  form  devised  bj'-  Thompson 
(Fig.  275)  has  a  very  suitable  angle,  but  possesses  the  objection- 
able spoon-shaped  blade.  This  latter,' reduced  to  about  half  its 
thickness,  as  we  have  altered  it,  forms  a  very  serviceable  instru- 
ment;  it  must,  however,  be  borne  in  mind,  that  with  a  curved 
instrument  there  is  a  sacrifice  of  power. 

For  u[)pcr  wisdom-teeth,  or  their  roots,  the  use  of  the  elevator 
may  be  attended  with  such  disastrous  consequence;^,  that  it  is 
well,  as  a  rule,  to  forbid  its  employment.  The  force  being  exerted 
in  the  direction  of  the  tuberosity  of  the  upper  jaw,  this  portion 


EXTRACTION  OF  ROOTS  OF  TEETH, 


299 


of  tlie  bone  mny  be  readily  detached,  and  with  it,  perhaps,  which 
is  more  im})Ortant,  tlie  haniular  process  of  tlie  internal  pterygoid 


Fig.  273. 


Fiff.  274. 


Fiff.  275. 


Shows  elpvator  with  its  hladps 
at  an  angle  to  the  liandles,  right 
and  left  instruments. 


An  elevator  the  blade       Shows  the  elevator  of  Thompson, 
of  which  can  be  set  at  right  and  left  instruments, 

any  angle. 


plate,  causing  deafness  on  that  side,  and  thus  unpleasantly 
demonstrating,  practically,  the  function  recently  attributed  to 
the  circumflexus-palati  muscles:  nevertheless  we  have  witnessed 
recently  the  same  complication  occurring  in  the  employment  of 
the  forceps,  and  in  the  hands  of  one  who  could  only  be  charac- 
terized as  a  most  careful  and  successful  operator.  This  process 
of  bone  is  at  times  so  slightly  attached  to  its  surroundings,  as  in 
the  case  just  noticed,  that  interference  with  the  latter  must 
ahiiost  of  necessity  cause  its  separation.  An  instrument  even 
more  likely  to  produce  this  result  than  the  elevator,  is  one  de- 
signed for  the  removal  of  wisdom-teeth,  and  resembling  a  pair 
of  bone-cutting  forceps,  with  the  blades  bent  at  rather  more  than 
a  right  angle  to  the  handles:  'when  closed,  the  blades  form  a 
smooth  inclined  plane  along  which  the  tooth  glides.  In  its  em- 
ployment, say  for  an  upper  wisdom-tooth,  the  open  blades  are 
closed  forcibly  between  that  tooth  and  the  second  molar — very 
much  in  the  manner  that  one  would  adopt  if  it  were  desired  to 


300 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


cut  away  the  wisdom-tooth  with  the  tuherosity — with  the  in- 
tention of  causing  the  tooth  to  slide  along  the  smooth  inclined 
plane  formed  by  the  blades  when  thus  closed. 

The  elevator  may  be  used  in  a  manner  different  from  the  fore- 
going, especially  in  the  case  of  loose  and  temporary  roots,  viz., 
by  applying  its  point  firmly  against  them,  and  then  pushing 
upwards,  downwards,  or  laterally,  as  the  case  may  demand. 

For  very  fragile  roots,  of  single-fanged  teeth  more  especially, 
an  instrument  having  at  one  termination  a  conical  screw  has  at 
times  been  employed  (Fig. -276).     The  root  must  be  cleared  of 

Fiir.  276. 


Shows  two  forms  of  screw  iustriuaeuts  for  cxtnu-tiiig  roots  of  toeth. 


softened  dentine,  and  tlie  screw  is  then  inserted  into  its  interior. 
We  are  amongst  the  very  few  who,  in  tliis  country  at  least,  have 
exjjerienced  its  application  upon  ourselves.  The  process  was 
somewhat  tedious  but  the  results  quite  satisfactory.  Other  in- 
struments for  the  removal  of  roots  of  teeth  have  been  devised 
and  employed,  but,  as  they  are  seldom  used,  we  think  a  descrij>- 
tion  of  them  will  only  tend  to  complicate  tiie  subject. 

[The  temporary  teeth  should  rarely  be  extracted  when  more 
force  ia  required  than  the  fingers,  protected  by  a  napkin  or  a 
scoop  excavator,  are  capable  of  exerting.  When,  however,  a 
forceps  is  required,  selection  from  the  smaller  ones  figured  and 
described  will  accomplish  the  object.] 


EXTRACTION  OF  ROOTS  OF  TEETH.  301 

The  roots  of  the  temporary  molars  are  more  (liveri!;ent  in 
proportion  to  their  crowns  than  those  of  the  permanent  ones, 
and  are  conseqnently  more  liable  to  fracture  in  their  removal; 
tliey  are  generally,  however,  very  readily  removed  with  a  small 
elevator.  Cases  do,  thongh  rarely,  occur,  in  which  the  roots  of  a 
lower  temporar}"  molar  so  envelop  its  permanent  successor,  that 
both  come  away  together  ;  but  a  more  than  casual  occurrence  of 
this  would  reflect  the  reverse  of  credit  on  the  operator.  Tem- 
porary teeth  during  the  stage  of  absorption  are  at  times  in  actual 
union  at  spots  with  the  surrounding  bone,  an;!  in  their  removal 
yield  w^ith  a  snap,  strongly  suggestive  of  fracture  ;  membranous 
union  yielding  may  also  give  the  same  sound,  and  so  character- 
istic, that  a  bystander  often  exclaims,  "It  is  broken!"  To  one 
nnacquainted  with  the  appearances  a  tooth  undergoing  absorp- 
tion presents,  the  conviction  is  that  a  portion  is  left;  and,  as 
both  sight  and  touch  often  reveal  the  presence  of  tooth-substance 
the  instrument  is  again  applied,  and  an  undeveloped  bicuspid  is 
disinterred. 

[The  surest  and  probably  the  best  safeguard  by  which  to 
avoid  the  above  accidents  is  to  fill  and  retain  the  deciduous 
teeth  until  absorption  renders  their  removal  a  very  simple  and 
easy  operation.] 

To  the  medical  student  who  may  have  patiently  followed  us 
thus  far  through  the  present  chapter,  we  can  well  imagine  the 
feelings  of  dismay  with  which,  after  our  condemnation  of  the  key 
as  an  instrument  unjustifiable  in  the  present  day,  he  has  had 
instrument  after  instrument  heaped  upon  him  to  supply  its  place; 
and  he  will  probably  exclaim,  "  This  is  a  methodical  way  of  shut- 
ting me  out  from  ever  undertaking  an  extraction  through  the 
costliness  of  the  instruments  necessary."  To  such  an  one  we 
would  reply,  that  we  have  only  been  attempting  to  describe  the 
very  best  manner  in  which  the  operation  of  extraction  can  be 
performed,  and  we  may  now  for  his  satisfaction  inform  him, 
that  a  set  consisting  of  seven  forceps  and  an  elevator  will,  with 
a  moderate  amount  of  experience,  and  the  faculty  for  adaptation, 
serve  him  well  for  all  but  quite  extraordinary  cases. 


302    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


CHAPTER    XV. 

DIFFICULTIES  AND  COMPLICATIONS  OCCURRING  IN 
EXTRACTION. 

We  must  now  consider  some  of  the  difficulties  and  compli- 
cations that  may  he  expected  in  the  operation  of  extraction.  A 
very  common  difficulty  is  great  resistance  to  our  efforts  on  the 
part  of  the  tooth,  and  our  judgment  as  well  as  our  skill  will  be 
taxed  in  deciding  how  much  force  we  may  lawfully  employ.  We 
may  expect  to  find  teeth  of  a  yellowish  shade,  and  somewhat 
worn  on  their  crowns,  especially  about  middle  age  and  in  per- 
sons of  wiry  constitution,  more  difficult  to  remove  than  large 
light-colored  ones  in  younger  persons.  The  size  of  the  crowns 
will  be  no  criterion,  as  the  fangs  or  their  firmness  may  be  out 
of  all  proportion  to  them. 

[Indeed  large  crowns  are  not  seldom  found  upon  quite  ordi- 
nary or  even  small  roots  and  vice  versa.  The  distinct  and  well 
defined  cusps  are  likewise  a  common  accompaniment  of  com- 
paratively well  pronounced  and  spreading  roots,  and  teeth 
whose  crowns  have  the  cusps  presenting  the  ajipearanceof  being 
fused  together  will  often  have  their  roots  nearly  parallel  and 
somewhat  joined.  In  fact  it  would  seem  to  be  profitable  to 
study  these  organs  as  made  up  of  germs  that  have  undergone 
more  or  less  distinct  segmentation.  The  central  incisor  presents 
a  very  faint  trace  of  the  cingulus  upon  the  palatine  face,  and 
an  almost  conical  root.  As  we  pass  backward  the  develop- 
ment of  the  tubercle  resembles  still  more  a  cusp  in  the  canine 
tooth,  and  finally  in  the  bicuspid  it  is  not  uncommon  to  find 
the  pulp  canals,  roots,  and  crowns  almost  divided.  The  molars 
present  a  still  further  tendency  in  the  above  direction.] 

A  tooth,  especially  a  first  or  second  molar  standing  alone, 
will  often  prove  unusually  hard  to  remove.  Our  judgment  will 
often  be  sorely  taxed  in  such  cases,  but  we  may  well  lay  down 
as  a  rule,  that  the  practitioner,  especially  if  a  strong  man,  should 


DIFFICULTIES,    ETC.,    IN     EXTRACTION.  303 

never  expend  the  whole  of  the  strength  he  can  summon  on  any 
tooth  ;  the  amount  necessary  to  be  exerted  may  be  great,  but 
must  be  restricted  Avithin  limits;  happily  with  the  forceps  it 
is  hardly  possible  to  do  tlie  damage  formerly  witnessed  with 
the  key.  It  is  extremely  unpleasant  to  send  a  patient  away 
with  an  aching  tooth  in  situ,  but  in  most  cases  we  have  found  a 
temporary  cessation  of  pain  in  a  tooth  the  removal  of  which 
has  been  attempted,  whilst  we  n)ay  almost  for  certain  give  the 
assurance,  that,  siionld  the  tooth  again  become  tender,  it  will 
also  become  somewhat  loose.  In  hospital  practice  we  haveliad, 
on  many  occasions,  patients  come  to  us  for  the  removal  of  teetli 
which  had  resisted  eftbrts  that  we  should  consider  dangerous 
and  unwarrantable,  but  in  whom,  in  most  cases,  the  teeth 
yielded  to  a  moderate  amount  of  force.  Some  days,  however, 
had  elapsed  since  those  eftbrts,  the  result  of  which  was  inflam- 
mation, with  softening  about  the  alveolus  and  the  alveolo-den- 
tal  membrane.  Young  practitioners  are  apt  to  attribute  success 
in  such  cases  to  their  superior  skill  ;  time  and  experience  will, 
however,  set  them  right  in  such  matters.  A  tooth  may  be  frac- 
tured when  only  a  modei'ate  amount  of  force  is  employed,  and 
that  skilfully  ;  and  we  are  convinced  that  some  teeth  are  more 
liable  to  this  than  others.  We  have  had  patients  whose  state- 
ment has  been  that  they  have  never  had  a  tooth  removed  in  its 
entirety.  A  tooth,  the  attachments  of  which  are  of  greater 
strength  than  its  own  cohesive  force,  must  of  necessity  yield 
by  fracture,  as  will  a  rotten  carrot  when  attempted  to  be  pulled 
from  the  ground.  In  such  cases,  should  the  remaining  portion 
prove  very  firm,  we  may  have  to  employ  judgment  as  to  the 
length  of  time  for  which  we  are  to  persevere  in  our  eftbrts  to 
remove  it ;  it  might  turn  out  that  we  are  attempting  an  impossi- 
bility, as  evidenced  at  times  by  the  abnormal  form  of  its  roots 
or  growths  upon  them.  Should  a  living  pulp  be  left  attached 
to  the  remaining  portion,  our  eftbrts  should  be  more  persistent 
than  if  it  had  come  away  from  it ;  but  in  the  latter  cases  re- 
peated applications  of  carbolic  acid  will  be  of  much  service. 

The  form  and  direction  of  the  fangs  are  a  common  source  of 
difiiculty  ;  the  single-fanged  teetli  njay  have  the  roots  spirally 
twisted  or  bent  at  almost  any  angle.  The  molars  may  have 
their  fangs  so  divergent  or  convergent  (Fig.  277  c,  d)  that  their 
removal,  except  singly,  would  be  almost  an  impossibility  ;  and 


304:        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

here  tire  dividing  forceps  will  prov^e  of  good  service  (see  Figs.  237, 
242).     Ill  the  case  of  enlarged  or  twisted  single  roots  they  may, 

Fiff.  277. 


Teeth  which  from  the  form  and  direction  of  their  fangs  would  present  a  considerable  resistance 
in  their  removal ;  a,  lower  canine  with  excessively  long  fang  ;  6,  lower  bicuspid,  fang  curved  ; 
c,  upper  molar  with  four  very  divergent  fangs  ;  d,  lower  molar  with  long  and  convergent  fangs. 
Copied  from  specimens  in  our  possession  and  drawn  actual  size. 

as  a  last  resource,  have  their  alveoli  trephined  over,  and  thus 
be  got  out  (Fig.  278),  hut  this  should  be  done  only  in  case  of 
great  pain  being  set  up  by  them. 

Fi2:.  278. 


A  trepliine  for  removing  the  alveolar  process  in  front  of  a  tooth. 

Teeth  may,  owing  to  abnormal  forms  in  their  crowns  (Fig. 
279),  be  rendered  more  difHcult  of  removal,  no  ordinary  instru- 

Fiir.  279. 


A  front  and  lateral  view  of  a  malformed  upper  third  molar,  to  which  the  forceps  of  ordinary 
construction  could  not  be  properly  adjusted  ;  a,  front  or  buccal  aspect ;  b,  side  or  approximal 
aHpect. 

ment  being  capable  of  adaptation  to  them  ;  and  the  positions 
assumed  by  teeth  in  regard  to  their  neighbors  may  wholly  pre- 
vent the  em[>loyment  of  the  ordinary  instruments,  or  at  all 
events  in  the  usual  directions.  This  condition,  the  result  of 
crowding,  is  not  unfrequently  met  with  in  the  lower  incisors  ;  an 
incisor  may  be  placed  so  directly  before  or  behind  other  teeth 


DIFFICULTIES,   ETC.,   IN    EXTRACTION. 


305 


that  there  will  be  no  space  in  the  former  for  the  posterior  blade, 
or  in  the  latter  for  the  anterior  blade,  to  be  applied.  To  meet 
such  cases,  forceps  havino-  a  very  narrow  posterior  or  a  very 
narrow  anterior  blade  are  constructed  (Fig.  280) ;  but,  as  these 

Fig.  280. 


Forceps   for  extractiug  lower  incisors  and  ciispulati  when  crowded  internally  or  externally. 
lu  one  instrument  the  inner,  and  in  the  other  instrument  the  outer,  blade  is  made  very  narrow. 

narrow  blades  are  very  apt  to  nip  off  the  crown,  we,  as  a  rule, 
prefer  employing  one  of  the  ordinary  forms  of  root-forceps,  grasp- 
ing the  tooth  laterally,  and  pressing  the  blades  towards  the 
alveolus  at  an  angle  to  the  crown.  For  the  teeth  of  the  upper 
jaw  similar  forceps  to  those  before  mentioned  are  constructed  (Fig. 
281),  but  to  these  we  apply  the  same  remarks  as  in  the  case  of 
the  teeth  of  the  lower  jaw. 

Fiff.  281. 


Forceps  for  extracting  upper  incisors  and  cuspidati  when  crowded  internally  or  externally. 

The  dental  surgeon  may  be  called  upon  to  remove  teeth  Avhich 
are  only  partially  erupted,  or  even  not  erupted.  Misplaced  or 
supernumerary  teeth  appearing  in  the  palate  are  at  times  almost 
impossible  to  remove  without  cutting  away  some  of  the  over- 
hanging alveolus:^  it  is  best  in  such  cases  to  wait  until  these 

'  This  object  cau  be  most  effectually  attained  by  Cattlin's  forceps  (Fig.  282), 
which  are  provided  with  serrated  blades  and  a  stop  which  lieeps  them  open  at 
a  given  distance. 
20 


306    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

are  more  fully  erupted.  The  lower  third  molars  are  often  a 
source  of  considerable  trouble  before  they  are  fully  erupted, 
setting  up  abscesses  of  considerable  extent  in  their  immediate 
neighborhood,  or  at  some  distance  from  them.  From  their 
position  when  much  crowded  it  is  almost  impossible  to  remove 

Fie;.  282. 


Cattlin's  alveolar  forceps  with  saw-edged  blades  for  cutting  through  alveolar  process,  to  give 
a  firm  grasp  on  teeth,  otherwise  not  obtainable.  They  are  provided  with  a  stop  to  keep  the  blades 
at  a  fixed  distance  apart. 

them,  their  crowns  being  partially  covered  by  the  second  molars 
in  front,  and  the  coronoid  processes  behind  ;  and  it  is  therefore 
necessary  at  times  in  such  cases  to  sacrifice  the  second  molar. 
We  should  have  naturally  expected  that  under  these  conditions 
the  third  molar  Would  have  lost  its  vitality;  and  have  still 
continued  to  be  some  source  of  trouble;  but  cases  have  oc- 
curred, in  which  all  trouble  and  discharge  disappeared  soon 
after  the  removal  of  the  second  molar.  In  many  of  these  cases, 
a  further  complication  exists,  from  the  contraction  of  the  mus- 
cles which  close  the  mouth  :  this,  however,  may  be  generally 
overcome  by  very  gradually  introducing  between  the  teeth 
wedges  of  soft  deal  of  increasing  size,  until  sufficient  room  is 
obtained,  which  for  the  elevator  will  only  be  that  sufficient  to 
raise  the  tooth  out  of  its  socket.  Under  an  anaesthetic  the 
mouth  ma}'  be  forcibly  opened  either  by  the  screw-dilator,  or  by 
an  instrument  that  we  devised  several  years  ago  for  such  cases 
(Fig.  283),  constructed  somewhat  like  a  pair  of  forceps,  but 
reversed  at  the  hinge,  so  that  by  compressing  the  handles  we 
can  open  the  blades :  the  latter,  protected  by  some  soft  substance, 
are,  when  closed,  pressed  between  the  teeth  or,  if  there  be  none, 
the  gums  ;  and,  the  handles  being  forcibly  pressed  towards  each 
other,  the  muscular  resistance  is  overcome  and  the  mouth 
opened.^ 

'  Much  more  recently  an  instrument  on  precisely  the  same  principle  was 
devised  by  our  friend  F.  Mason,  who  was  unaware  of  the  existence  of  ours. 
We  are  bound  to  say  that  his  form  is  in  most  respects  superior  to  ours,  and  has 


DIFFICULTIES,    ETC.,    IN    EXTRACTION. 


307 


Teeth  which  are  impacted,  or  from  other  causes  uiieruiited, 
often  become  a  source  of  serious  trouble,  and  in  attempting  to 


Fi''.  283. 


The  author's  mouth-opener  (or  gag)  described  ia  the  text.    The  cut  on  the  right  side  shows  the 

instrument  as  applied. 

treat  such  cases  we  may  overlook  the  actual  condition.  Of  three 
such  instances  we  will  give  a  brief  account.  The  first  was  that 
of  a  hidy,  rather  past  middle  age,  who  had  suffered  for  a  con- 
siderable time  from  abscesses  in  the  right  side  of  the  neck:  in 
looking  for  a  cause  we  discovered  a  small  opening  in  the  gum 
over  the  spot  at  which  a  wisdom-tooth  would  be  developed.  A 
steel  probe  (Fig.  284),  introduced  fully  half  an  inch  below  the 
surface,  struck  against  a  hard  substance,  and  conveyed  a  strong 


been  strongly  recommended  by  the  late  Sir  W.  Fergusson  for  employment  in 
the  operation  of  staphylorapliy.  In  one  particular,  however,  it  is  less  service- 
able, viz.,  in  the  greater  space  occupied  by  the  blades  wlien  closed,  making  it 
difficult  to  introduce  them  between  the  teeth  with  the  mouth  closed  or  nearly 
closed. 


308 


3IA^'UAL  OF  DENTAL  SURGERY  AND  PATHOLOGY, 


impressiou  that  that  substance  was  enamel.  Chloroform  was 
administered,  a  free  incision  made,  and  after  a  time,  for  the 
bleeding  was  very  copious  and  much  interfered  throughout,  a 
portion  of  the  crown  of  a  tooth  was  rendered  visible  ;  bone  was 


Fiar.  384. 


Steel  probes  of  various  curves  useful  for  detecting  unerupted  teeth. 


cut  away  round  it,  and  eventually  it  was  prised  out  in  two 
pieces.  The  patient  was  more  or  less  under  chloroform  for  the 
space  of  two  hours.  The  troublesome  symptoms  subsided  soon 
after  the  operation. 

The  second  case  was  that  of  a  gentleman,  past  middle-life, 
who  had  suffered  for  twenty-four  years  from  what  had  been 
reo-arded  as  disease  of  the  inferior  maxilla  on  the  right  side;  as 
in  the  former  case,  a  hard  substance  presented  itself,  which  was 
detected  at  some  distance,  about  two-thirds  of  an  inch,  from  the 
surface.  When  struck  by  a  probe  it  likewise  gave  the  impres- 
sion of  being  tooth-substance.  To  avoid  the  trouble  from 
hemorrhage  as  in  the  former  case,  the  patient  was  first  subjected 
to  nitrous  oxide,  when  a  free  incision  was  made  into  the  swollen 
tissues,  and  the  opening  well  dilated  with  the  linger,  lie  was 
then  allowed  to  recover  consciousness,  and  the  position  of  the 
tooth,  which  could  not  be  seen,  was  ascertained  as  nearly  as  pos- 
sible. When  bleeding  had  ceased,  chloroform  was  administered, 
and  the  tooth,  first  loosened  with  an  elevator,  was  without 
much  difficulty  removed  by  a  pair  of  long-bladed  root-forceps. 
This  case  was  rendered  interesting  by  the  length  of  time  during 
wliich  its  true  cause  had  remained  overlooked;  espe<;ially  as  the 


DIFFICULTIES,    ETC.,    IN    EXTRACTION.  309 

jaw  liad  on  one  occasion  boon  trepliinod  in  tlio  hope  of  opening 
up  an  abscess. 

The  third  case  was  that  of  a  gentleman  aged  seventy-two, 
who  had  suftered  for  some  few  months  from  a  tumor  in  the 
neck,  also  u{)on  tlie  right  side.  As  it  was  increasing  rapidly, 
an  operation  had  been  advised  by  an  eminent  provincial  prac- 
titioner. The  friends,  however,  desired  first  the  opinion  of  a 
London  surgeon  s[)ecially  eminent  in  such  cases.  The  result 
of  his  examination  was  the  conclusion  that  the  tumor  was 
most  probably  a  lymphati<3  gland,  enlarged  l)y  the  irritation  set 
up  by  an  unerupted  lower  wisdom  tootli  of  tiiat  side.  Nitrous 
oxide  first,  and  then  chloroform,  as  in  the  last  case,  were  ad- 
ministered, and,  after  much  difficulty,  and  the  free  use  of  the 
gouge,  the  whole  of  a  three-fanged  tooth  in  several  fragments 
was  removed.  Within  forty-eight  hours  the  growth,  which  was 
about  the  size  of  a  tig,  had  diminished  by  one-half,  and  in  a 
fortnight  had,  with  the  exception  of  a  little  thickening,  wholly 
disappeared.  The  reader  may  well  understand  the  difficulties 
to  be  encountered  in  such  cases  ;  happily  tliey  are  rare,  yet  they 
all  occurred  in  the  practice  of  one  individual,  Sir  J.  Paget, 
whose  accumen,  in  at  once  discovering  their  true  causes,  cannot 
but  excite  our  admiration. 

In  the  removal  of  a  tooth  in  a  young  subject,  it  would  not 
be  at  all  an  unlikely  thing  for  a  neighbor  to  come  out  with  it, 
if  care  and  precaution  were  not  exercised  ;  in  such  cases,  the 
adjoining  tooth  will  be  seen  generally  to  move  with  the  one 
operated  on.  We  believe  that  in  such  cases  no  bony  septum 
exists  between  the  two  teeth,  and  the  periosteum  is  common  to 
both.  When  this  occurs,  the  operator  should  firmly  press  with 
the  left  thumb  upon  the  crown  of  the  tooth  so  seen  to  move, 
and  should,  in  using  the  forceps  or  elevator,  not  apply  more 
force  than  can  be  controlled  by  the  thumb;  until  a  severance  is 
felt,  when  the  removal  may  be  safely  accomplished.  Should 
an  adjoining  tooth  be  partially  or  wholly  removed  from  its 
socket,  it  should  be  immediately  reinstated,  and  firmly  pressed 
into  its  place,  when  it  will  most  probably  again  become  united 
to  its  membranes,  and  as  serviceable  as  if  nothing  had  occurred. 
In  removing  teeth  of  young  persons  with  the  elevator,  espe- 
cially where  an  adjoining  tooth  has  not  been  erupted,  great  care 
must  be  exercised,  or  the  unerupted  tooth  may  be  disinterred 


310 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY, 


also ;  it  is  best,  tlierefore,  if  possible,  always  to  employ  the  for- 
ceps in  such  cases. 

Teeth,  as  previously  stated,  are  sometimes  found  united  to 
each  other  at  their  roots;  the  resistance  to  removal  which  such 
will  offer  can  well  be  imagined.  It  is  almost  impossible  to 
diagnose  such  condition  or  the  existence  of  extensive  exostosis 
beforehand  ;  yet,  as  before  noticed,  an  application  of  the  electric 
light  such  as  we  once  witnessed  at  the  Odontological  Society 
might  materially  aid  us  in  such  matters.  The  appliance  was 
the  invention  of  Hart,  electrician  of  Edinburgh,  and  so  perfectly 
illuminated  the  mouth  that  the  fangs  of  the  teeth  could  be  seen 
through  the  structures  which  enveloped  them. 

Whilst  exercising  everj-  care,  we  find  it  at  times  impossible 
to  avoid  removing  with  the  tooth  small  portions  of  the  alveolar 


Fisr.  285. 


Fiff.  286. 


Upper  first  molar  tooth  with  a  portion  of  the 
external  alveolar  plate  attached  to  it.  From 
the  form  that  the  portion  of  hone  pre.sents  and 
its  absence  at  ihe  extremity  of  the  fanirs,  it 
would  have  been  almost  impossible  to  remove 
the  tooth  without  removinjr  it  a«  well. 


Upper  third  molar  with  the  tuberosity  of  the 
sui>erior  maxilla  attached  to  it.  In  this  case 
also  the  form  of  the  bone  rendered  its  re- 
moval with  the  tooth  a  matter  of  necessity. 
This  case  is  alluded  to  at  pp.  29S  aud  299. 


process  attached  to  it.  Thus,  especially  with  the  upper  first 
molars,  the  outer  alveolar  wall  is  often  extremely  thin  and  slight, 
and  these  thin  portions  yield  more  readily  than  does  the  alveolo- 
dental  membranes  to  which  they  are  united.  AVe  need  not 
distress  our  patients  by  an  exposition  of  the  same,  or  lead 
them  to  imagine  that  something  untoward  has  occurred,  but 
mentally  congratulate  them,  as  these  sharp  portions,  if  left, 
are  often  a  source  of  worry  and  inconvenience  until  they  either 
se[tarate  or  are  absorbed.  Where  the  alveolar  process  is  abnor- 
mally high,  and  becomes,  as  it  frequently  does,  conspicuous 
above  the  surface  when  several  contiguous  teeth  have  been  re- 
moved, we  may  with  advantage  pare  off'  the  prominent  por- 
tions with  suitable  bone-cutting  forceps  (tig.  287);  the  process 


DIFFICULTIES,    ETC.,    IN    EXTRACTION, 
Fis?.  287. 


311 


TJirce  forms  of  forceps  suitable  for  cutting  away  projecting  portions  of  alveolar  process,  etc. 

of  healing  will  be  thereby  much  accelerated.  [For  the  above 
}»urpose  the  wedge-cutter  (Fig.  288)  will  generally  be  sufficiently 
strong  and  serviceable.] 

Should  larger  portions  of  alveolar  process  be  fractured,  their 
removal  or  retention  will  depend  upon  their  dimensions  :  if  they 
at  all  involve  the  stability  of  adjoining  teeth,  our  efforts  should 
be  directed  to  their  retention.  Cases  of  direct  transverse  fracture 
of  the  lower  jaw  have  occurred,  the  result  of  attempting  to  re- 
move a  tooth  ;  and  under  the  hands,  we  believe,  of  those  whose 
skilfulness  as  operators  has  never  been  questioned.  We  can  un- 
derstand this  most  unfortunate  complication  occurring  when 
only  a  very  moderate  amount  of  force  has  been  employed:  pre- 
parations of  the  lower  jaw  are  to  be  met  with,  where  more  than 
one-half  of  the  thickness  of  the  bone  has  been  lost  by  alveolar 
abscess.  Where  extensive  alveolar  abscess  has  occurred,  it  will 
be  well  for  us  to  bear  this  fact  in  mind  ;  and  should  such  acci- 
dent occur,  the  dental  surgeon  ought  to  be  the  best  person  to 
rectify  it. 

A  more  common  accident  attendant  upon  extraction  of  teeth 
than  the  foregoing  will  be  dislocation,  partial  or  complete,  of  the 
inferior  maxilla;  it  most  frequently  occurs  during  the  adminis- 
tration of  an  anaesthetic,  doubtless  in  consequence  of  the  relaxed 


312    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY 

Fio;.  288. 


Wedge  cutter. 

condition  of  the  muscles.  To  reduce  it,  the  two  thumbs  of  the 
operator,  well  protected  by  a  nuitkin  or  folds  of  lint,  should  be 
placed  upon  the  back-teeth,  and,  whilst  the  jaw  is  thus  dcpi-essed 
at  its  posterior  portions,  its  anterior  portion  should  be  elevated 


DIFFICULTIES,    ETC.,    IN    EXTRACTION.  313 

by  the  pressure  of  tLe  fingers  under  tlie  cliin.  In  adopting  this, 
the  ordinary  process,  we  have  never  met  with  any  difficulty  in 
accomplishing  our  object. 

Cases  have  occurred  in  which  the  lower  teeth,  especially  the 
third  molars,  by  embracing  the  interior  dental  nerve  with  their 
fangs,  have  of  necessity  in  their  removal  caused  the  severance  of 
the  latter,  and  we  have  known  a  case  where  paralysis  of  the  same 
nerve  followed  the  extraction  of  a  third  molar,  which  could 
only  be  accounted  for  as  the  result  of  shock.  To  the  [)atient 
the  result  of  this  injury  is  distressing,  as  from  loss  of  sensation 
the  saliva  trickles  from  that  side  of  the  mouth  without  his 
knowledge,  and  the  consequent  effort  to  retain  it  within  the  lips. 
The  nerve  usually  more  or  less  unites,  and  resumes  its  function 
after  a  time. 

It  will  often  be  difficult  to  determine  which  tooth  is  actually 
the  seat  of  pain  when  several  contiguous  ones  are  much  dis- 
eased:  percussion,  or  the  application  of  cold  to  each,  will  gene- 
rally reveal  the  true  offender,  but  it  will  occasionally  happen 
that  the  seat  of  pain  is  at  some  distance  from  the  spot  referred 
to  by  the  patient — actually  in  the  opposing  jaw.  [A  single  drop 
of  cold  water  may  be  put  upon  any  smooth,  cold  surface,  and  by 
means  of  a  syringe,  previously  chilled  and  emptied,  the  drop  of 
water  may  be  carefully  drawn  into  the  end  of  the  nozzle,  from 
which  it  can  be  blown  into  a  suspected  cavity.  Should  the  pulp 
be  exposed  and  living,  a  sharp  pain,  generally  of  very  short  dura- 
tion, is  experienced.  Pain  upon  pressure  or  from  slight  tapping 
on  the  tooth  with  a  light  excavator  handle,  will  indicate  perios- 
teal trouble.]  If  we  only  followed  patients'  impressions,  we  should 
often  remove  teeth,  which  though  undoubtedly  bad,  are  not 
at  the  time  of  their  visit  the  cause  of  their  suffisrings.  We  must 
bear  in  mind  that  pain,  set  up  by  a  diseased  tooth,  does  not 
always  cease  with  its  removal ;  and  this  is  especially  the  case 
where  inflammation  has  set  up  in,  or  extended  to,  its  periosteum. 
The  pain  after  the  laceration  of  membranes  in  such  a  condition 
is,  we  can  well  comprehend,  usually  very  acute,  and  may  last 
for  several  hours,  according  to  the  stage  of  inflammation  at 
which  the  tooth  was  removed.  We  have  found  the  most  ser- 
viceable application  at  the  time  to  be  a  mixture  of  pure  carbolic 
acid  with  a  small  quantity  of  chloroform,  apjdied  on  cotton  to 
the  alveolus.     If  the  pain  continue  for  several  days,  soothing 


31-4    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

fomentations,  especially  poppy  with  chlorate  of  potash  (see  p. 
52),  will  be  found  the  most  efficacious.  [It  is  well  always  to 
relieve  the  pain  before  extracting  the  tooth.  For  this  purpose, 
in  the  case  of  exposed  pulps,  use  morphia  paste  or  toothache- 
drops,  or  chloral  and  camphor,  or  camphor  dissolved  in  chloro- 
form. The  toothache-drops  are  made  by  adding  to  a  saturated 
solution  of  morphia  in  sweet  spirits  of  nitre  an  equal  measure 
of  oil  of  cloves,  and  to  every  drachm  of  this  mixture  should  be 
added  ten  drops  of  fluid  extract  of  gelseminum,]  A  cold  taken 
after  extraction  is  often  the  explanation  given,  but  we  think 
that  in  many  cases  we  see  on  the  mucous  membrane  precisely 
what  we  should  on  an  external  surface  describe  as  an  erythe- 
matous inflammation,  but  of  which  cold  may  undoubtedly  be 
the  originator.  The  healing  of  a  vacated  alveolus,  is  chiefly,  no 
doubt,  effected  by  granulation  ;  still  in  many  cases  the  overhang- 
ing mucous  membrane  so  nearly  meets,  that  it  may  be  regarded 
as  partially  by  first  intention  ;  but  all  wounds  on  healthy  mucous 
membranes  heal  more  readily  than  on  outer  surfaces,  as  from  their 
positions  they  partake  more  of  the  character  of  subcutaneous 
ones.  In  the  above-mentioned  cases,  w^e  find  the  mucous  mem- 
brane surrounding  the  alveolus  swollen,  congested  and  everted, 
and  the  alveolus  commonly  occupied  by  a  slough.  [Compressing 
the  alveolar  Avails  between  the  index  finger  and  thumb  will  often 
be  sufficient  to  arrest  the  bleeding,  and  assist  in  healing  by 
replacing  them  to  such  a  distance  as  will  make  the  smallest 
amount  of  cicatricial  tissue  necessary  for  the  healing.] 

A  not  uncommon  complication  occurring  after  extraction  is 
abnormal  ht^morrhage:  this  may  be  primary  or  secondary. 
There  is  always  more  or  less  bleeding  immediately  after  the 
removal  of  a  tooth,  greater  and  prolonged  if  there  has  been 
long  standing  inflammation,  the  vessels  under  such  conditions 
having  less  tendency  to  contract.  Siiould  it  continue  to  any 
unusual  extent,  we  may  employ  cold  by  iced  water,  exposure 
to  the  air,  tannic  acid,  or  even  perchloride  of  iron,  or  plugging; 
but  the  last  is  seldom  necessary  witli  the  primary  haemorrhage. 
The  secondary  haemorrhage  is  much  more  difficult  of  control, 
and  generally  occurs  under  the  following  or  similar  circum- 
stances. The  patient  who  has  undergone  removal  of  a  tooth 
in  the  day,  and  with  no  specially  untoward  circumstances, 
wakes  up  in  the  night  with  his  mouth  full  of  blood,  and  finds 


DIFFICULTIES,    ETC.,    IN     EXTRACTION,  315 

tliat  a  considerable  quantity  has  been  running  from  it  during 
sleep.  He  probably  feels  somewhat  faint  from  the  loss, and,  if  he 
do  not  seek  advice  and  assistance,  it  may  goon  until  fatal  syncope 
supervenes.  Death  from  this  cause,  especially  in  remote  country 
places,  is  not  very  rare,  and  even  does  occur  at  times  in  large 
towns.  The  cause  of  the  secondary  hremorrhage  is  of  a  constitu- 
tional rather  than  a  local  character,  and  is  stated  to  be  more 
dependent  upon  a  diseased  condition  of  the  muscular  coats  of  the 
bloodvessels,  than  upon  a  want,  in  the  blood,  of  the  property 
of  forming  a  firm  coagulum  or  clot.  Both,  no  doubt,  may  pro- 
duce this  condition,  the  former  probably  in  those  who  are  ever 
liable  to  it,  /.  c.,  persons  suffering  from  haemophilia  or  the  hfemor- 
rhagic  diathesis,  the  latter  in  those  who  may  have  only  been 
subject  to  it  at  particular  times.  Where  such  tendency  is  known 
to  exist,  we  must  exert  all  resources  before  extracting  a  tooth  ; 
and,  if  compelled  to  do  so,  must  plug  the  alveolus  in  the  manner 
which  we  shall  now  describe,  and  which,  we  are  happy  to  say, 
has  never  failed  in  our  hands,  although  w^e  have  been  called  to 
cases  where  other  means  proved  of  no  avail,  and  where  the 
patients  appeared  fast  sinking.  A  piece  of  matico  leaf,  which 
has  been  immersed  in  water  for  a  few  minutes,  should  be  rolled 
up,  the  under-surface  of  the  leaf  outwards,  into  as  many  little 
pellets,  about  the  size  of  a  pea,  as  the  roots  of  the  tooth  removed : 
a  narrow  tent  of  lint,  about  one-third  of  an  inch  wide,  and  about 
four  or  five  inches  in  length,  should  be  prepared,  as  also  a  pad 
of  the  same  about  tiie  size  of  a  chestnut.  The  mouth  should  be 
cleansed  from  blood,  and  the  swket  carefully  cleared  of  coagula 
with  cotton,  and  immediately  after  the  removal  of  the  cotton  a 
pellet  of  matico  introduced  into  each  alveolus  and  pressed  firmly 
down  with  the  broad  compressing  plugger;  upon  the  matico  the 
tent  of  lint  is  with  the  same  instrument  to  be  firmly  packed  layer 
upon  layer,  until  the  alveolus  is  filled  a  little  above  the  surface 
of  the  gum,  and  upon  this  is  placed  the  pad,  which  should 
extend  above  the  crowns  of  the  adjoining  teeth,  and  be  pressed 
upon  when  the  mouth  is  closed.  The  mouth  should  be  kept 
closed  by  a  bandage  passing  round  the  head  and  under  the 
chin.'     The  horizontal   position,  with   the  head  and  shoulders 

'  We  have  known  several  cases  where  the  application  of  B.  W.  Richardson's 
styptic  colloid  has  proved  most  successful. 


316        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

slightly  raised,  should  be  maintained,  and  the  apartment  kept 
cool,  and  hot  and  spirituous  drinks  avoided;  but,  should  the 
patient  appear  sinking,  some  stimulant  must  be  administered, 
and  the  patient  kept  warm;  as  a  very  little  lowering  of  tempe- 
rature, after  great  loss  of  blood,  may  suffice  to  extinguish  the 
spark  of  life;  the  occurrence  of  convulsions  will  indicate  for 
certain  the  latter  treatment,  if  not,  in  addition  to  it,  transfusion 
of  blood.  Strong  beef  jelly  should  also  be  given  in  small  quan- 
tities, but  at  frequent  intervals,  the  finger  of  a  bystander  being 
kept  pressed  upon  the  pad  whilst  the  mouth  of  the  patient  is 
opened.  Gallic  acid,  gr.  v-x  ;  tinct.  ferri  perchlor.  ^n.  xv-xxx  ; 
or  acetate  of  lead,  gr.  j-iv,  may  be  administered.  Care  should 
be  taken  to  allow  the  plug  to  remain  until  it  is  pressed  out  of 
the  alveolus  by  plastic  formation  beneath  it;  but  in  very  severe 
cases  we  must  be  prepared  for  a  return  of  the  hsemorrhage  when 
this  takes  place. 

[The  extracted  tooth  will  serve  as  a  very  perfect  fitting  com- 
press ;  likewise  cotton -wool  with  gallic  or  tannic  acid  worked 
through  it  while  dry,  and  then  packed  in  quickly,  so  that  the 
absorption  of  moisture  and  consequent  swelling  will  assist  in 
producing  pressure  upon  every  part  of  the  bleeding  surface. 
The  tincture  of  the  perchloride  of  iron  is  not  so  well  thought  of 
by  some,  on  account  of  the  danger  of  sloughing  and  secondary 
hiemorrhage  after  its  application.^] 

Should,  however,  our  efl:orts  at  controlling  the  bleeding,  by 
pressure  or  other  means,  prove  unavailing,  even  after  we  have 
substituted  a  gutta-[)ercha  or  vulcanite  plate  for  the  lint  pad, 
and  this  has  been  attended  with  success,  we  must,  as  a  last  re- 
source, be  prepared  to  cut  off  the  supply  of  blood  from  the  part, 
although  this  would  probably  be  worse  than  useless  where  the 
hseniorrhagic  diathesis  is  well  marked.  In  other  cases  it  may 
prove  successful.  Should  this  step  be  imperative,  we  are  dis- 
posed  not  to  recommend  the  course  which  is  generally  adopted, 
viz.,  diligation  of  the  common  carotid  artery,  but  rather  to  ad- 

[•  "Touching  a  bleeding  gum  with  Monsel's  solution,  or  with  nitrate  of 
silver,  is  dangerous  practice.  The  only  alarming  cases  of  hfcmorrhagc  ever 
seen  by  the  author  Iiave  been  the  results  of  those  applications."  A  System  of 
Oral  Surgery,  by  Jas.  E.  Garretson,  M.D.,  D.D.S.  Philadelphia:  J.  B.  Lip- 
pincott  &  Co.,  1881.] 


DIFFICULTIES,    ETC.,    IN    EXTRACTION.  317 

vise  tliligation  of  the  external  carotid  (Fig.  289),  aiul  for  the 
reason  that  most  disastrous  consequences  are  very  likely  to  re- 
sult from  shutting  oft"  one  of  the  four  princi[)al  supplies  of  blood 

Ficr.  289. 


\ 

A  diagrammatic  representation  of  the  arteries  of  the  right  side  of  the  neck. 

to  the  brain.  Anatomical  considerations  would  also  lead  us  to 
fear  secondary  haemorrhage  when  a  collateral  circulation  has 
been  established  through  the  free  inosculation  of  vessels  at  the 
base  of  the  brain — AVillis's  circle — but  experience  points  to  the 
fact  that  this  is  not  the  case.  The  operation  of  tying  the  exter- 
nal carotid  in  the  living  subject  is  not  as  simple  as  the  same 
operation  on  the  common  trunk,^  but  this  is  a  minor  considera- 
tion when  compared  with  the  greater  danger  to  life  from  the 

'  If  the  case  be  one  in  which  the  hfcmorrhagic  diathesis  exists,  there  may  be 
less  danger,  on  the  "whole,  in  tying  the  common  carotid  artery,  as  fewer  vessels 
will  be  interfered  with  than  in  the  operation  of  tying  the  external  carotid. 


3L8        MANUAL    OF    DENTAL    SURftERY    AND    PATHOLOGY. 

latter.  Before  proceeding  to  this  extreme  resort,  we  should 
naturally  try  the  effects  of  pressure  on  the  vessels,  and  this 
might  be  kept  up  for  a  moderate  time,  but,  owing  to  the  nature 
of  the  structures  pressed  upon,  could  not  be  tolerated  for  any 
lengthened  period.  In  the  case  of  haemorrhage  from  a  tooth  of 
the  lower  jaw,  the  inferior  dental  artery  could  be  readily  got  at, 
and  obliterated  in  its  j^assage  through  the  bone. 


ANAESTHESIA.  319 


CHAPTER    XVI. 

AX.ESTHESIA. 

When  performing  the  operation  of  extraction  under  an  anaes- 
thetic, we  maj  have  to  modify  to  a  considerable  extent  the  rules 
that  we  have  laid  down  for  the  process  in  general ;  and,  as  this 
has  in  the  present  day  become  a  very  important  branch  of  the 
practice  of  dental  surgery,  we  feel  that  we  may  with  advantage 
devote  a  chapter  to  its  consideration. 

The  history  of  anaesthetics  is  so  intimately  connected  with 
Dental  Surgery,  that  we  think  that  a  brief  outline  of  it  may  not 
be  out  of  place  in  this  volume. 

Wliile  we  bear  in  mind  that  the  ancients  had  made  attempts, 
more  or  less  successful,  to  alleviate  or  wholly  obliterate  the  pain 
attendant  upon  surgical  operations,  the  history  of  anaesthetics 
must  really  date  from  the  hour  when  a  dental  practitioner  had, 
at  his  own  suggestion,  a  tooth  removed  with  a  total  absence  of 
sensation. 

J^itrous  oxide,  or  protoxide  of  nitrogen,  was  discovered  by 
Priestley,  and  its  properties  investigated  by  Sir  H.  Davy,  who 
actually  suggested  that  it  might  be  used  as  an  anassthetic ;  but 
this  suggestion  probably  never  met  the  eye  or  reached  the  ear  of 
Horace  Wells,  and,  so  far  as  we  are  cognizant,  was  not,  as  such 
ever  acted  upon.  Wells's  inspiration  came  from  witnessing  a 
slight  accident  occur  without  pain  being  felt,  at  a  popular 
lecture  by  one  Colton,  who  was  illustrating  upon  one  of  his 
audience  the  exhilarating  properties  and  ludicrous  effects  of 
nitrous  oxide  gas — a  very  common  practice  some  years  ago.  The 
failure  of  Wells  when  attempting  to  employ  the  agent  for  long 
surgical  operations,  owing  no  doubt  to  defective  apparatus,  led 
him  to  discontinue  his  investigations,  and  to  embark  in  unsuc- 
cessful speculation  resulting  in  a  sad  premature  death.  For- 
tunately for  humanity,  a  former  associate  of  Wells  took  up  the 
matter  and  with   more  successful  results.      With  Morton,  to 


820        MANUAL    OP    DENTAL    SURGERY    AND    PATHOLOGY. 

whom  "we  are  alluding,  must  be  associated  the  name  of  Jackson  : 
the  latter  supplied,  while  the  former  administered,  ether,  and  for 
the  extraction  of  a  tooth.  The  result  was  a  perfect  success,  and 
ether,  being  more  easy  of  administration  than  nitrous  oxide, 
soon  proved  available  also  in  extensive  surgical  operations. 

[In  August,  1840,  Dr.  Horace  Wells^  is  claimed  to  have  re- 
marked, '•''That  he  believed  that  a  man  might  be  made  so  drunk  by 
this  gas  (nitrous  oxide)  or  some  similar  agent,  that  dental  or  other 
operations  might  be  performed  upon  him,  ivithout  any  sensation  oj 
pai7i  on  the  part  of  the  patient." 

On  the  11th  of  September,  1844,  Dr.  Horace  Wells  proved 
upon  himself  the  correctness  of  his  views  by  having  Dr.  J.  M. 
Rio-crs,  of  Hartford,  Conn,,  extract  a  tooth  for  him  while 
he  was  under  the  influence  of  the  gas  administered  by  Mr. 
Colton. 

Dr.  P.  A.  Wilhite,  of  Anderson,  S,  C,  claims,  according  to 
Dr.  J.  Marion  Sims,^  of  New  York,  that  in  the  "fall  of  18^39," 
when  he  was  seventeen,  he  etherized  a  negro  boy  for  fun  at  a 
quilting  party  and  ether  frolic  near  Athens,  Ga.  Subsequently, 
when  a  medical  student  of  Crawford  .W.  Long,  M.D.,  at 
Jefferson,  Jackson  Co.,  Georgia,  he  mentioned  the  matter,  and 
with  his  preceptor  and  three  fellow  students  they  all  tried  its 
intoxicating  power  at  various  times,  and  Dr.  Long  etherized  Mr. 
James  M.  Venable,  and  extirpated  ]>ainlessly  a  tumor  from  the 
back  part  of  the  patient's  neck.  The  report  in  the  Southern 
Medical  and  Surgical  Journal,  Dec.  1849,  says,  "  He  gave  no 
evidence  of  suffering  during  the  operation,  and  assured  me  after 
it  was  over,  that  he  did  not  experience  the  slightest  degree  of 
pain  from  its  performance." 

"This  operation  was  performed  on  the  30th  of  March,  1842; 
a  second  one  upon  the  same  person  was  performed  on  June  6th, 
1842." 

The  same  operator  followed  these  by  other  successful  admin- 
istrations, as  on  July  3d,  1842,  for  amputation  of  a  toe  ;  Sept. 
9th,  1843,  for  exsection  of  three  small  cystic  tumors  from  the 
liead :  on  the  8th  of  Jan.  1845,  for  amputation  of  two  fingers.] 

['  Sec  pp.  4  and  5  of  a  pamplilot  entitled  "  Dr.  Wells,  the  Discoverer  of 
Anicstiiesia  "     Published  by  llobert  Larter,  44  Ann  St.,  New  York,  18G4.] 

[2  Virginia  Medical  Monthly  for  May,  1877.  Richmond,  Landon  B. 
Edwards,  M.D.] 


ANyESTIIESIA, 


321 


Fiff.  290. 


The  news  of  tlie  great  discovery  soon  crossed  tlie  Atlantic, 
and  Robinson,  a  dentist,  had  the  lionor  of  first  administering 
ether  in  this  country.  The  pungency  of  ether,  togetljer  with  a 
degree  of  difficulty  in  its  administration,  led  to  the  investigation 
of  the  properties  of  bodies  of  the  same  class,  and  amongst  these 
chloric  ether  was  administered  by  Jacob  Bell.  As  often  happens 
in  such  experiments,  the  cases  selected  proved  unfortunate  ones  ; 
the  after-affects  were  unsatisfactory, 
and  this  discouragement  led  to  the 
abandonment  of  that  which  under 
other  circumstances  would  no  doubt 
have  anticipated  the  brilliant  dis- 
covery of  Sir  J.  Simpson.  Chloric 
ether  we  now  know  to  be  a  mixture 
of  chloroform  and  alcohol,  but  its 
composition  was  not  at  that  time 
understood,  because  chloroform,  as 
such,  had  not  been  isolated.  It  was 
not  long,  however,  before  Waddy,  of 
Liverpool,  obtained  this  fluid  pure, 
and  sent  some  of  it  to  Sir  James 
Simpson,  who  established  the  value 
of  its  anaesthetic  properties  ;  and  in 
a  little  tinie  chloroform,  owing  to  its 
more  agreeable  flavor  and  easier  ad- 
ministration than  ether,  almost  en- 
tirely superseded  the  latter,  at  least 
in  this  country.  The  agent  soon 
became  employed  almost  whenever 
requested,  and  administered  wit]^ 
probably  even  less  precaution  than 

is  nitrous  oxide  in  the  present  da}- ;  when  lo!  a  patient  died 
suddenly  under  its  influence:  "because  they  do  not  know  how 
to  give  it,"  remarked  one  whose  great  experience  had  led  him 
to  a  rash  confidence  in  himself;  but  a  few  days  had  scarcely 
passed  when  the  like  sad  event  occurred  under  his  own  hands. 
A  reaction  now  set  in,  and,  as  might  be  expected,  stronger 
than  was  warranted;  some  medical  authorities  refusing  almost 
entirely  to  sanction  its  use  in  any  case.  Other  compounds 
were  carefully  investigated,  mixtures  of  chloroform  and  ether, 

21 


B.  W.  Ricliurdsiiir.s  I'ther-spray  ap- 
paratus. By  means  of  a  hand  oi'  foot 
bellows  air  is  forced  into  a  graduated 
jar  containini^  very  highly  rectified 
ether,  which  is  projected  from  a  fine 
jet  in  the  form  of  a  spray,  and  this 
evaporating  rapidly  produces  intense 
cold.  In  the  drawing  above  is  shown 
Welsh's  tongue  or  cheek  holder  at- 
tached to  the  jet-piece. 


322    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

chloroform  and  alcohol,  or  the  three  together,  were  tried,  but 
with  little  better  results,  while  some  few  reverted  to  ether, 
which  had  never  been  wholl}^  discarded.  The  idea  of  produc- 
ing local  anre^thesia  naturally  occupied  the  minds  of  many.  A 
frozen  part  is  painless,  and  Arnott  froze  small  tumors  with  a 
mixture  of  ice  and  salt.  Teeth  were  frozen  in  their  sockets,  by 
an  ingenious  apparatus  devised  by  W.  Blundell,  a  dentist,  and 
removed  without  painful  sensation.  [Dr.  Branch,  of  Chicago, 
is  mentioned  by  some  as  the  inventor  of  a  similar  apparatus  for 
using  pulverized  ice  and  salt.  The  danger  of  producing  frost- 
bite was  not  so  great,  probably,  with  the  neat  instrument  fig- 
ured above,  as  tlie  parts  can  be  continually  kept  in  view,  and 
the  moment  blanching  of  the  tissues  commences  the  a[)plication 
may  be  stopped.]  Frost-bitten  wounds  do  not  generally  heal 
up  satisfactorily,  and  the  sensation  of  freezing  structures  (espe- 
cially inliamed  ones)  is  not  the  most  agreeable,  otherwise  no 
doubt  tlie  ingenious  instrument  for  producing  cold  through 
evaporation, — the  ether-spray  devised  by  B.  W.  Richardson, 
(Fig.  290)  the  discoverer  of  bichloride  of  methylene  and  many 
other  an^estlietics — would  be  very  generally  employed. 

Electricity  also  had  a  trial,  on  the  supposition  that  a  nerve 
could  only  convej'  one  species  of  sensation  at  a  time,  and  that 
whilst  it  was  occupied  in  conducting  that  of  electric  shock,  it 
would  fail  to  convey  that  of  pain.  The  more  recent  discovery  of 
Brown-Sequard — that  for  various  sensations  special  channels  of 
conduction  are  essential — did  not  enter  into  the  calculation.  Pa- 
tients who  parted  with  teeth  whilst  under  the  influence  of  electric 
shock  were  puzzled  to  realize  how  much  of  what  they  felt  was 
shock,  and  how  much  was  pain:  but  their  general  conclusions 
were,  that  it  was  as  pleasant  without  the  electricity  as  with  it. 
Nineteen  years  had  elapsed  since  the  short-lived  triumph  of 
Horace  Wells,  and  little  had  been  done  in  the  mean  time  to 
fui'ther  investigate  the  anaesthetic  properties  of  nitrous  oxide; 
still  from  time  to  time  we  in  this  country  heard  of  our  brethren 
in  the  New  World  speaking  cautiously,  yet  on  the  whole  favor- 
ably, of  it  for  dental  }»urposes. 

Colton  had  not  forgotten  how  well  peo{>le  took  the  gas,  and, 
in  comparison  with  other  anaesthetics,  how  much  better  they 
recovered  from  it,  and  was  led  to  introduce  its  employment  upon 
a  large  scale  in  New  York.     Armed  with  such  credentials  as 


ANiESTIlESTA.  323 

tlic  rec(M"d  of   some  20,000    successful    {vdniiiiistnitious,  Coltori 
visited  Piiris  in  tlie  Exliihitiou  yciir  of  1878,  and  there  exhibited 
thisauciit.     The  faculty  in  Fran-cc  did  not  appear  to  espouse  it 
warmly,  l)ut  it  was  otherwise  with  some  Asnerican  practitioners 
resident  there,  especially  T.  W.  Evans,  a  dentist,  and  ^[arion 
Sims,  a  surgeon-acccmcheni".     In    the   spring  of   the  following 
year, the  former  visited  London,  and  administered  the  gas  before 
the  staff  of  the  Dental  Hospital.     The  value  of  an  agent  evidently 
so  safe,  and  so  well  suited  for  dental   purposes,  was  oidy  too 
apparent,  and  within  a  week  of  witnessing  Evans's  administra- 
tion we  had  arranged  an  ajtparatus,  prepared  the  gas,  and  given 
it  successfully  to  four  patients.     Our  readers,  acquainted  with 
the  present  modes  of  and  aj-pliances  for  administering  nitrous 
oxide,  would  smile  at  the  cumhrous  and  rough    apparatus  at 
iirst  employed.     A  large  India-rubber  bag  or  balloon  contained 
tlie  gas,  connected  b^-  a  long  tube  with  a  wooden  mouth-[)iece 
with  inlet  and  outlet  valves.     The  mouth-[»iece  was  placed  be- 
tween the  patient's  teeth,  and  the  lips  compressed  over  it  by  the 
lingers,  wliilst  the  linger  and  thumb  of  a  bystander  unceremo- 
niously closed    the  patient's  nostrils.     To  the  liberal    donations 
of  Evans,  who  contributed  a  fund  for  investigating  the  merits 
of  nitrous  oxide,  must  be  attributed  in  agreat  degree  the  rapidity 
with  which  our  knowledge  of  the  pro[»erties  of  the  gas,  and  the 
improved  modes  of  its  administration,  have  come  alxnit.' 

The  greatest  of  these  im[»rovements  has  been  the  vending  of 
the  gas,  first  in  a  compressed  and  finally  in  a  liquid  form  ;  other- 
wise its  bulk,  or  the  inconvenience  of  tbe  practitioner  having  to 
prepare  it  on  his  own  premises,  would  ever  have  been  a  serious 
drawback  to  its  general  use. 

Of  the  angesthetics  generally  employed  in  Dental  Surgery  we 
will  first  speak  of  that  last  mentioned,  the  earliest  introduced, 
as  we  have  shown,  and,  under  our  present  state  of  knowledge, 
the  most  suitable  by  far  for  the  majority  of  such  short  operations 
as  the  extraction  of  teeth.  A  very  safe  and  rapidly  acting  an- 
aesthetic is  the  desideratum  for  such  cases,  and  this  we  have  in 
nitrous  oxide.     That  it  is  tlie  safest  anassthetic  of  any  that  wc 

'  Vide  report  of  a  committee  to  inquire  into  the  Value,  etc.,  of  Protoxide  of 
Nitrogen  as  an  Anivsthetic,  etc.  Trans.  Odout.  Soc,  vol.  i.  (new  series)  p. 
31,  and  vol.  v.  (do.)  p.  11. 


324    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

possess,  there  can  be  little  doubt ;  but  this  mny  arise  rather  from 
the  method  of  employing  it  than  from  anythino;  peculiar  to  its 
composition.  To  fairly  compare  it  with  other  anjesthetics,  it 
would  be  necessary  to  administer  it  for  the  same  periods  of 
time.  Still  it  must  not  be  regarded  as  perfectly  safe,  for,  al- 
though out  of  several  hundreds  of  thousands  of  administrations 
in  this  country  only  two  deaths  have  been  recorded,  and  it  is  very 
doubtful  whether  one  of  these,  that  which  occurred  at  Exeter,' 
was  attributable  directly  to  the  gas,  it  is  yet  by  no  means  a 
difficult  matter  to  destroy  life  with  it ;  only  let  the  administra- 
tion be  pressed  a  little  too  far,  and  death  must  result  as  a  conse- 
quence: therefore  we  would  insist  that  it  should  be  administered 
only  by  competent  and  experienced  persons,  and,  as  a  rule,  never 
single-handed  ;  departure  from  this  rule  is  the  assumption  of  an 
unwarrantable  responsibility. 

It  cannot  be  stated  for  certain  how  nitrous  oxide  produces 
its  anaesthetic  effects  ;  there  can,  however,  be  little  doubt  but 
that  it  is  not  owing  to  its  decomposition  in  the  lungs  :  the  ex- 
periments of  Hermann,  Frankland,^  the  writer,^  and  others  have 
set  that  question  at  rest;  and  the  probability  is,  that  its  action 
is  due  rather  to  the  absence  of  oxygen  in  the  blood.  ISTitrogen, 
it  might  then  be  supposed,  would  answer  the  purpose  as  well; 
but  nitrogen,  although  it  may  be  for  a  short  time  readily  re- 
spired, is  not  like  nitrous  oxide,  soluble  in  the  blood,  and  there- 
fore is  not  capable  of  replacing  its  oxygen.  In  addition  to  the 
results  of  chemical  determination,  the  following  facts  are,  as  we 
have  elsewhere  pointed  out,^  conclusive  ones  to  negative  the 
notion  that  nitrous  oxide  is  decomposed  in  the  blood.  Nitrous 
oxide  consists  of  two  volumes  of  nitrogen  and  one  volume  of 
oxygen,  occu}iyi)ig  the  space  of  two  volumes;  if  a  quart  of  the  gas 
be  respired  to  and  from  a  bladder,  after  the  lungs  have  been 
emptied  of  air  as  far  as  possible,  the  contents  of  the  bag  will 
nearly  disappear.  What  has  become  of  it?  it  has  not  been  de- 
com[)Osed  in  the  lungs,  as  the  same  bulk,  i.  e.,  two  volumes, 
would  have  been    returned  to  the  bag;  it  must,  therefore,  have 

'  Report  on  a  Death  from  Nitrous  Oxide.     Trans.  Odon.  Soc,  vol.  v.  (new 
series)  p.  83. 

2  Report  on  Nitrous  Oxide.     Trans.  Odont.  Soc,  vol.  v.  (now  series)  p.  13. 

3  Ibid.,  p.  21. 

*  St.  Bartbolomew's  Hospital  Reports,  vol.  v.  p.  103. 


ANAESTHESIA. 


325 


entered  tlie  blood,  and,  if  decomposed  in  the  latter,  what  be- 
comes of  the  nitrogen,  set  free,  as  every  chemist  must  admit  it 
would  be,  and  wliich  would  at  once  [trove  fatal  to  life  ?  We 
suspect  that  those  constituents  of  the  blood  which  have  an 
affinity  for  oxygen  have  the  like  for  nitrous  oxide,  and  thus 
travel  with  it  in  the  circuit,  but  without  its  being  decomposed. 
The  appearances  of  the  patient  inhaling  it  are  those  which  are 
manifested  when  the  blood  in  the  arteries  and  capillaries  as- 
sumes a  venous  character. 

Nitrogen  when  respired,  if  it  c;in  enter  the  circulation  at  all, 
can  do  so  onl}-  in  intiiiitesimal  quantities,  and  hence  the  oxy- 
gen in  the  blood,  following  a  general  law,  is  yielded  up  to  the 
tissues  the  more  slowly  as  its  quantity  is  diminished  ;  in  other 

Fis.  291. 


Complete  apparatus  for  generating  nitrous  oxide  gas.  A,  box  for  supporting  tlie  flask  contain- 
ing ooe,  two,  or  more  lbs.  of  nitrate  of  ammonia,  and  also  for  protecting  the  gas  flame,  F,  from 
currents  of  air.  The  gas  when  generated  first  passes  through  water  in  bottle  Xo.  1,  it  next 
passes  through  a  solution  of  proto-sulphate  of  iron  (.3  oz.  to  IJ^  pt  )  contained  in  bottle  No.  2, 
and  finally  through  a  solution  of  caustic  potash  (1  oz.  to  \}4  pt.)  contained  in  bottle  No.  .3.  The 
other  letters  apply  to  .\sh's  and  Kirby's  iugenious  apparatus  for  regulating  the  supply  of  gas  to 
the  burner,  and  extinguishing  the  fiame  at  the  proper  period. 


CAr 


words,  it  is  retained  in  the  circulation  much  longer  than  when 
it  is  replaced  at  tlie  lungs  by  another  gas  ;  hence  the  anaesthesia 
produced  by  nitrogen  is  slow  and  imperfect  as  compared  with 
that  produced  by  nitrous  oxide,  which,  by  replacing  the  oxygen, 
more  readily  abstracts  it  from  the  blood. 


32l")        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

Xitrous  oxide  gas  ma}'  be  readily  prepared  by  beating  nitrate 
of  ammonia  in  a  glass  flask  (Fig.  291)  and  collecting  tbe  pro- 
ducts over  water,  wbich  may  be  stored  in  a  gasometer  (Fig.  292), 
or  by  pressure  in  wrought-iron  vessels  (see  Fig.  293).  The  salt 
undergoes  a  double  decomposition,  resulting  in  nitrous  oxide 
and  water.  As  tbns  prepared  the  gas  will  contain  impurities, 
viz.,  some  of  tbe  higber  combinations  of  nitrogen  with  oxygen, 


Fiff.  293. 


Fiff.  293. 


(jasometcr  fur  collecting  and  storing  nitrous 
oxide  gas. 


A  simjile  lorm  of  apparatus  for  admin- 
istcriuif  nitrous  oxiilo.  It  consists  of  a 
box  to  hold  the  apparatus,  in  which  a 
clamp  securely  fixes  a  hottle  of  liquid 
gas :  this  latter  is  connected  with  an 
ludia-rubber  bag  by  a  flexible  tube:  a 
flexible  tube  of  larger  dimensions  con- 
nects the  bag  with  a  Clover's  two-way 
stopcock  which  is  attached  to  the  face 
piece. 


and  often  carbonic  acid  from  tbe  presence  of  carbonate  of  am- 
monia in  tbe  nitrate.  It  should,  tberefore,  before  being  collected 
in  a  gasometer,  j)a8s  through  a  series  of  Woulffe's  bottles, 
containing  respectively:  1,  water;  2,  solution  of  protosulphate 


ANiESTHESIA. 


32T 


of  iron;  and  3,  solution  of  caustic  potash.  The  cliief  precaution 
necessary  is,  to  see  that  the  lieat  is  gradually  ai>plied  and  evenly 
maintained. 

Fortunately,  however,  practitioners  are  saved  the  trouhle  of 
preparing  their  gas,  it  being  sup[ilied  to  them  in  the  liquid  form 
hy  several  firms,  who  guarantee — a  most  important  matter — the 
safety  of  the  wrought-iron  vessels  which  contain  it. 

FiK.  294. 


Nitrons  oxide  apparatus  consisting  of  an  iron  stand  with  drawer  to  hold  necessary  appliances. 
The  stand  supports  two  bottles  of  !<as  so  arranged  that  in  case  of  one  failing  the  other  can  be  em- 
ployed iBarth's  plan,  we  believe).  The  gas  passes  from  either  bottle  to  a  sausage-shaped  bag, 
and  directly  from  this  to  the  face-piece,  a  two-way  stopcock  only  intervening.  This  arrangement 
(Clover's)  possesses  great  advantages,  as  the  gas  comes  to  the  patient  more  readily  than  when 
its  progress  is  impeded  by  the  friction  of  a  tube.  Above  the  gas-bottles  is  shown  an  arrangement 
for  administering  ether  with  the  gas.  It  consists  of  a  vessel  to  receive  the  ether,  under  the  sur- 
face of  which  a  tube  dips:  by  turning  a  two-way  stopcock  the  current  of  s.'!**  '*  made  to  pass 
through  the  ether.  An  outer  vessel  for  holding  hot  water  is  also  shown,  but  we  have  not  found 
it  necessary  even  in  the  coldest  weather. 

With  regard  to  the  mode  of  administration,  etc.,  we  rnay  first 
describe  the  apparatus,  which,  in  a  simple  form,  may  consist  of 


328    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

a  wrought-iron  bottle  of  liquid  gas  supported  in  a  box  or  strong 
firm  frame,  so  that  it  can  readily  be  opened  by  the  hand  or  foot 
of  the  administrator  (Fig.  293).  A  more  perfect  arrangement 
is  when  two  bottles  (Fig.  294)  nre  so  connected  that,  on  one 
failing,  the  other  may  be  brought  into  use.  By  a  small  flexible 
tube  communication  is  made  between  the  bottle  or  bottles  and 
a  bag  constructed  of  sheet  India-rubber,  of  oval  or  sausage  form, 
and  capable  of  containing  about  one  gallon,  connected  at  its 
opposite  extremity  almost  directly  with  the  face-piece,  it  being 
important  that  that  there  should  be  the  least  possible  impediment 
to  the  passage  of  the  gas  from  or  to  the  bag.  A  two-way  stop- 
cock of  large  dimensions  serves  to  close  the  bag,  and  at  the  same 
time  to  admit  air  to  the  face-piece  (Fig.  295)  which  is  attached 

Fig.  295. 


Clover's  face-piece  and  two-way  stopcock.  The  face-piece  is  constructed  of  thin  sheet  lead  or 
composition  metal,  capable  of  being  bene  to  the  form  of  the  face,  and  covered  with  leather.  At! 
the  metal  is  apt  to  break  away,  a  thin  but  unyielding  metal  is  to  be  pi-cferred.  The  face-piece  as 
now  supplied  has  an  air  or  water-pad  where  it  meets  the  patient's  face,  which  makes  it  fit  air- 
tight: A,  represents  the  outlet  or  expiratory  valve;  B,  the  inlet  or  inspiratory  valve.  In  the 
apparatus  which  we  employ  there  is  only  the  expiratory  valve,  the  plan  now  adopted  by  Clover. 
E,  shows  where  a  supplemental  bag  for  economizing  the  gas  can  be  attached,  but  this  on  the  plan 
which  we  pur.sue  is  unnecessary  ;  C,  shows  the  two-way  stopcock. 

to  it:  the  latter  we  prefer  constructed  of  thin  but  unyielding 
metal,  provided  with  an  outlet-valve  only,  capable  of  being 
closed  whilst  the  edges  which  approximate  to  the  face  are  sur- 
rounded with  an  India-rubber  water-jjad.  The  object  of  having 
an  outlet-valve  only  capable  of  being  closed,  is  to  enable  the 
administrator,  at  a  certain  stage  of  the  proceeding,  when  the 
product  of  respiration  is  almost  entirely  pure  nitrous  oxide,  to 
permit  the  gas  to  be  breathed  over  again,  and  thus  greatly 
economize  it,  without  in  any  way  impairing  the  results,  a  condi- 


ANAESTHESIA.  329 

tion  entirely  dependent  upon  the  fact  that  the  gas  is  not  decom- 
posed in  the  system.  [It  is  doubtful  if  this  economical  use  of 
the  gas  is  justified,  as  more  or  less  of  excreta  from  the  lungs 
and  respiratory  track, as  epithelium,  mucus,  etc.,  must  find  their 
way  into  the  bag.] 

Before  applying  the  annestiietic,  the  operator  should  most 
thoroughly  decide  in  his  own  mind  what  he  intends  to  effect, 
and  should  also  take  into  consideration  the  fact  that  he  may  not 
be  able  to  accomplish  all  he  desires,  and  therefore  what  under 
the  conditions  had  best  be  attempted  first.  Thus  a  patient  may 
be  desirous  of  having,  say,  three  teeth  removed  ;  one  has  been 
causing  pain,  the  other  two,  though  diseased,  perhaps  not;  in 
such  a  case  the  one  giving  pain  should,  even  though  the  least 
convenient  to  the  operator  for  so  doing,  be  first  removed,  for  it 
would  be  distressing  for  the  patient  on  becoming  conscious  to 
find  his  enemy  still  in  permanence,  and  circumstances  might 
contra-indicate  his  taking  the  gas  a  second  time.  If  no  one 
tooth  has  been  especially  painful,  we  should  as  a  rule  remove 
lower  teeth  or  roots  before  u[»per  ones,  to  avoid  the  blood  inter- 
fering with'our  view;  roots  before  whole  teeth,  and  back  teeth 
before  front  ones,  for  the  same  reason  ;  nnd  it  is  generally  best, 
where  much  has  to  be  done  and  on  more  than  one  occasion,  to 
confine  the  operation  to  one  side  of  the  mouth  before  proceed- 
ing to  the  opposite.  [This  is  highly  recommended,  as  often 
enabling  the  patient  to  eat  with  the  unwounded  side  of  the 
mouth  until  the  opposite  one  has  healed.]  In  the  preliminary 
examination  of  the  mouth,  every  care  should  be  taken  to  avoid 
making  the  gums  bleed,  or  causing  the  patient  pain  or  anv  un- 
necessary fear  ;  3'et  the  inspection  should  be  conducted  most 
thoroughly,  so  that  the  position  of  the  teeth  or  roots  to  be  re- 
moved may  be  well  pictured  on  the  mind  of  the  operator  when 
the  face  is  obscured  from  view.  He  should  next  quietly  select 
his  instruments,  taking  care  to  have  not  ojily  those  most  handy 
which  he  is  sure  to  use,  bnt  also  an\^  which  he  may  chance  to 
require,  and  these  should  be  arranged  in  the  order  for  use  on  a 
small  table  or  bracket  close  at  hand.  [It  is  well  even  to  trj'  all  the 
instruments  laid  out  to  be  used  upon  the  teeth,  after  explaining 
to  the  patient  that  the  object  is  merely  for  observation  as  to  their 
fitness  and  adaptability.]  We  strongly  recommend,  in  opera- 
tions with  ansesthetics,  the  employment  of  as  few  instruments 


330    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

as  possible.  Time  is  a  very  important  element,  especially  in  the 
case  of  nitrous  oxide,  and  a  few  seconds  wasted  often  render 
further  administration  necessary;  but  this  does  not  mean  that 
we  are  to  attempt  at  any  time  to  use  an  unsuitable  instrument. 
Those  which  we  most  frequently  employ  in  such  operations  are 
the  upper  root-forceps  suitable  for  wisdom  teeth  (Fig.  268),  and 
the  lower  root-forceps  (Fig.  269).  The  curved  elevators  are  also 
very  serviceable  ;  with  one  of  these  we  can  often,  proceeding  from 
the  back  of  the  niouth  forwards,  remove  in  an  incredibly  short 
space  of  time  ten  or  more  roots  from  the  lower  jaw.  In  addi- 
tion to  ordinary  instruments  there  should  always  be  ready  at 
hand  a  few  small  sponges  attached  to  handles,  a  Clover's  spoon 
for  dejiressing  the  tongue  and  preventing  roots  from  falling  into 
the  throat,  a  pair  of  oesophagus  forceps,  a  tracheotomy-tul)e,  etc. 
Care  should  be  exercised  to  prevent  the  patient's  garments  from 
being  soiled. 

These  preliminaries  being  arranged,  it  is  well,  after  calmly 
telling  the  patient  that  you  are  ready,  to  assure  him  that  he  has 
nothing  to  do,  it  will  all  be  done  for  him,  he  need  not  even  try 
to  breathe  or  to  think  about  breathing,  that  "all  \V\\l  be  com- 
pleted in  a  minute  or  two  if  he  will  oidy  try  and  remain  quite 
passive."  We  are  convinced  that  the  complicated  instructions 
often  given  to  patients  about  breathing  are  a  mistake,  tending 
only  to  make  them  nervous  and  confused.  There  is  almost 
invariably  some  sensation  of  suffocation  in  inhaling  nitrous 
oxide,  and  this,  we  are  sure,  is  increased  by  commencing  with 
very  deep  respirations.  In  the  next  proceeding,  that  of  inserting 
the  prop  or  gag  (Fig.  296)  to  keep  the  mouth  open,  the  patient 
being  informed  of  its  object,  care  should  be  taken  to  stretch 
the  mouth  as  little  as  possible — but  yet  sufficiently  to  afford 
ample  room  for  the  instruments  being  ajiplied — and  to  see  that 
the  prop  is  secure  from  slipping.  S[iring-props  (Fig.  207)  are  in 
this  respect  most  to  be  depended  on,  but  all  com[)lications  render 
the  fracture  of  an  appliance  more  likely  to  occur,  and  this  has 
been  attended  with  a  fatal  result  in  one,  if  not  two  instances. 
Projis  made  of  hard  wood  or  vulcanite,  roughened  to  meet  the 
cusps  of  antagonizing  teeth,  and  secured  by  strong  cord  from 
entering  the  throat,  are  [)robal)ly  tiie  most  useful  and  simple. 
We  recommend  the  operator,  es[)ecially  the  less  ex[)erienced, 
after  inserting  the  prop,  to  take  a  view  of  the  mouth,  in  order 


ANESTHESIA, 


331 


to  enable  him  to  see  the  exact  relationshii)  of  tl)e  Icctli  to  the 
tongue,  etc.,  from  the  position  in  which  he  will  have  to  operate. 
The  patient  should  then  he  requested  to  close  tlie  lips  as  much 
as  possible,  which,  not  only  by  likewise  closing  the  jaws,  renders 


Fitr.  20G. 


Fiff.  297. 


Simple  form  of  mouth- proj)  or  gag,  con- 
structed of  hard  wood  or  vulcstnite,  for 
keeping  the  mouth  open  in  nitrous  oxide  ad- 
ministration. When  coupled  in  pairs  as 
shown  above,  the  one  not  in  use  prevents 
the  possibility  of  the  other  falling  into  the 
throat. 


McAdam's  mouth-prop.  Between  the  upper 
and  lower  portions  is  a  spring,  so  that  the  gag 
will  rise  if  the  patient  opens  his  mouth.  The 
extremities  touching  the  teeth  are  covered  with 
soft  vulcanite.  The  pin  shown  in  the  cut  is  for 
securing  the  spring  when  compressed,  and  also 
for  placing  the  prop  in  situ. 


the  position  of  the  [tro[)  more  secure,  but  also  permits  the  fixce- 
piece,  now  to  be  applied,  to  more  perfectl}'  include  the  mouth 
and  nares.  Upon  apjdying  the  face-piece  it  is  desirable  to  allow 
the  patient  for  a  few  seconds  to  breathe  air  through  the  two- 
way  stopcock  before  turning  on  the  gas;  it  is  also  well  not  to 
commence  with  the  bag  fully  distended  with  gas,  as  the  sudden 
pressure  is  startling  and  unpleasant.  A  nervous  patient  may 
soon  commence  movements  of  the  extremities,  or  resist  breath- 
ing; a  kind  but  firm  appeal  will  often  iiave  the  best  effect,  even 
wlien  the  patient  is  nearly  unconscious,  which  may  occur  from 
within  ten  seconds  to  two  minutes  of  the  inhalation;  should  it 
be  longer  than  the  latter  period,  we  may  infer  that  some  air  is 
inhaled  with  the  gas.  Time  then  affords  us  little  criterion  as  to 
the  anaesthetic  condition  having  arrived,  and  this  knowledge  can 
onl}'  be  attained  by  experience.  The  state  of  the  conjunctiva, 
or  the  more  sensitive  palpebrte,  is  also  no  sure  test;  a  patient 
may  be  unconscious  of  pain,  but  still  capable  of  such  reflex 
action  ;  or  be  conscious  of  pain,  and  yet  have  lost  it.  Respira- 
tion will  best  guide  us  in  the  matter,  and  an  experienced  antes- 
thetist  could,  from  the  vibraiions  conve3'ed  to  the  inhaler,  tell  in 
the  dark  when  lie  ousht  to  discontinue  the  administration.     He 


332    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

should  warn  the  operator  as  the  nionient  approaches,  and  when 
tlie  face-piece  is  removed  the  latter  should  at  once  commence. 
ISucb  operations  are  probably  more  rougbly,  because  more 
rapidly,  performed  under  nitrous  oxide,  but  still  it  will  be  best 
to  do  little,  and  that  thorouo;hly,  than  to  attempt  too  mucb  and 
fail.  It  is  never  well  for  the  student  to  attempt  extractions 
under  gas  until  he  has  acquired  considerable  dexterity  in  oper- 
ating without  it ;  otherwise,  we  predict,  he  will  never  become  a 
safe,  cautious,  and  dexterous  operator.  All  teeth  and  fragments 
when  detached  should  be  at  once  removed  from  the  mouth,  and 
here  Clover's  spoon  will  be  of  much  assis<tance  ;  but,  where 
teeth  raided  from  the  alveoli  are  firmly  attached  to  the  gum, 
the  operator  may  at  once  }>ass  on  to  other  teeth  ;  time  would 
be  uselessly  expended  in  removing  them,  or  the  gum  would  be 
unduly  lacerated.  They  can  be  best  separated  after  recovery, 
and  this  is  especially  the  case  with  lower  wisdom  teeth  when 
detached  by  the  elevator.  In  removing  teeth  from  the  lower 
jaw,  the  finger  that  protects  the  tongue  from  injury  may  per- 
chance press  back  that  organ,  and  so  close  the  glottis. 

The  operation  being  completed,  the  patient's  liead  should  be 
pressed  gently  forwards,  especially  if  there  be  much  haemorrhage, 
and  a  suitable  basin  held  under  the  chin.  This  position  it  is 
well  to  continue  for  some  half-niinute  or  so,  without  rousing  the 
patient  or  attempting  forcibl}^  the  removal  of  the  prop,  the  latter 
often  leading  the  lialf-conscious  j^atient  to  imagine  that  the 
operation  is  still  in  progress.  It  is  a  good  proceeding  to  remove 
the  patient  after  a  few  minutes  from  the  chair  to  a  sofa  or  couch, 
and  let  him  assume  the  serai-recumbent  posture  for  at  least  a 
quarter  of  an  hour,  or  much  longer  if  desirable;  the  patient 
should  also  be  counselled  to  keep  quiet  if  possible,  i.  e.,  without 
exciting  or  fatiguing  occupation,  for  the  remainder  of  the 
da}'.  We  have  frequently  found,  where  unpleasant  after-effects 
have  been  complained  of,  that  an  opposite  course  has  been  fol- 
lowed. Administrations  of  nitrous  oxide  may  in  most  cases  be 
repeated  at  least  once,  but  should,  if  possible,  be  avoided  on  the 
following  grounds.  Bleeding  of  the  mouth  may  be  a  cause  of 
inconvenience,  if  not  of  danger,  and  the  patient  usually  sntfers 
much  more  from  prostration  after  a  second  than  after  one  ad- 
ministration ;  and  it  will  probably  be  better  to  employ  nitrous 


ANESTHESIA.  333 

oxide  with  ether  in  lengthy  cases  tlian  to  repeat  nitrous  oxide 
administrations. 

In   describing    the   symptoms  or  appearances    indicative  of 
danger,  we   must   bear  in   mind   that   ha[ipily  fatal  cases  have 
been  so  rare  that  no  one  can  s[teak  from  large  experience.     The 
ordinary  appearance  of  a  patient  inhaling  nitrous  oxide  is  in 
most  cases  decidedl}'  alarming;  we  well    remember  the  first 
impressions  made  upon  us  and  upon  bystanders.     We  have  be- 
come accustomed  to  such  appearances,  but  yet  we  may,  if  care- 
less of  them,  overlook  the  real  indications  of  danger  which 
tliey  to  some  extent  mask.     In  some  cases  not  only  is  the  as- 
phyxiated ajipearance  strongly  marked,  but  convulsive  move- 
ments suggestive  of  an   e[>ileptic  attack  are  also  present,  and 
for  the  reason,  no  doubt,  that  we  have  in  these  cases  some  of  the 
conditions  which  exist  in  epileptic  seizure.     Provided  that  the 
patient  be  breathing  freely,  we  have  only  in  such  cases  to  sup[)ly 
fresh  air,  gently  slap  the  face  with  a  wet  towel,  and  protect  the 
patient  from  self-injury.      The   symptom  which   should    most 
impress  itself  upon   us,  as  indicating  danger,  is  a  cessation  of 
respiration  during  tlie  administration,  and  still  more  so  if  the 
inhalation  be  completed.     Sometimes  the  breathing  is  shallow, 
rapid,  and  pufiing,  very  commonlj'   so  with   nervous  females, 
and  cotnmencing  soon  after  the  inlialation  is  commenced  ;  in 
such   cases  the  air  in  the  lungs  is  but  slowly  exchanged,  the 
patient  is  longer  in  becoming  unconscious,  and  more  exhausted 
subsequently.     It  is  here  that  a  firm  request  to  breathe  more 
slowly  will  generally  be  of  avail.     A  little  later  in  the  admin- 
istration we  often  find  the  patient  forcibly  resisting  respiration, 
in  which  case  the  breath  may  be  held  for  eight  or  ten  seconds 
without  cause  for  alarm,  but  if  for  a  longer  period  the  face-piece 
should  be  withdrawn,  and,  if  that  produce  no  effect,  the  thorax 
should  be  firmly  pressed  upon,  and  after  a  respiration  or  two  of 
pure  air  the  [irocess  may  be  continued. 

The  truly  dangerous  condition  is  when  respiration  has  ceased, 
the  lungs  being  nearly  empty,  the  face  perfectly  immovable,  as 
in  death,  or  as  when  a  patient  is  breathing  through  a  tracheo- 
tomy-tube, and  the  countenance  being  livid,  the  eyeballs  con- 
gested and  turned  upwards,  and  the  temperature  of  the  body 
reduced.  Under  such  conditions,  which  on  one  or  two  occasions 
we  have  witnessed,  the  tongue  should  be  immediately  drawn 


334        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

forward  aiul  the  thorax  firmly  pressed  upon  ;  and,  if  this  course 
should  not,  after  one  or  two  efforts,  be  followed  by  natural  re- 
spiration, resort  should  be  had  at  once  to  artificial  respiration. 
In  carrying  this  out  we  believe  no  plan  can  be  more  effective, 
at  least  to  commence  with,  than  mouth  to  mouth  inflation  of 
the  lungs.  [This  has  been  very  highly  objected  to  in  this  coun- 
try  as  unnecessary  and  extremel}'  unclean,  it  being  claimed  that 
bellows  for  the  pur]:K)se  should  always  beat  hand.]  It  is  a  most 
disagreeable  process,  but  in  such  emergencies  a  good  deal  may 
be  sacrificed.  The  mere  pulling  forward  of  the  tongue  may,  by 
opening  the  larynx,  often  suffice,  as  the  nitrous  oxide  in  the 
lungs  would  soon  be  exchanged  for  air  by  the  law  of  diffusion 
of  gases;  but  the  respiratory  movement  also  no  doubt  conduces 
to  the  continuance  of  the  heart's  movements.  The  experiments 
made  hy  the  committee  a[)pointed  to  investigate  the  merits  of 
nitrous  oxide,^  showed  that  in  the  case  of  healthy  animals 
death  took  ytlace  in  the  following  oi-der  of  S3'mptoms: — the  in- 
halation having  been  continued  about  two  minutes  after  corh- 
plete  unconsciousness  was  attained,  the  respirations  became 
slower  and  slower,  with  an  increased  interval  between  every 
succeeding  one,  until  they  entirely  ceased;  during  the  same 
time  the  pulse  became  gradually  weaker,  but  the  heart's  action 
could  be  felt  for  some  time,  generally  about  30"  or  rather  longer, 
after  respiration  had  terminated.  In  these  experiments  the 
committee  invariably  found  that,  if  they  discontinued  the  ad- 
ministration before  respiration  had  ended,  the  animal  recovered 
without  assistance;  whei]  respiration  had  ceased,  but  the  heart's 
action  had  not  dono  so,  artificial  res[)i ration  resuscitated  the 
animal,  but  not  otherwise;  whilst  after  cessation  of  the  heart's 
action  no  means  that  are  known  to  us  could  restore  animation. 
It  should  be  borne  in  mind  that  the  animals  operated  upon  in 
these  experiments  were,  or  most  probably  were,  healthy  ones, 
otherwise  such  experiments  would  teach  us  without  hesitation 
that,  so  long  as  the  patient  is  breathing,  he  is  safe,  and,  so 
long  as  the  heart  continues  its  action,  artificial  respiration 
may,  we  should  almost  feel  confident,  resuscitate  him.  Unfor- 
tunately our  dangers  will  probably  not  occur  with  the  healthy 
but  with  the  unhealthy,  and,  if  we  have  to  deal  with  one  suffer- 

'  Op.  cit. 


AN/ESTIIESIA 


335 


ing  from  a  wenk  and  fatty  lieart,  liow  can  we  expect  the  action 
of  such  an  organ  to  continue  any  time  after  respiration  has 
ended?  Whilst  the  pulse  must  not  be  neglected,  there  can  he 
no  douht  that  the  respiration  should  occupy  our  chief  attention, 

Fig.  298. 


Electro-maguetic  appanitus  wliicli  maybe  employed  for  stiiijulating  the  heart's  action  when 
arrested  during  tlie  administration  of  an  auajsthetic. 

and  this  failing,  we  rush  immediately  to  our  sheet  anchor,  arti- 
ficial res]»iration ;  other  restonitives,  if  at  hand, — galvanism 
applied  at  the  phrenic  nerve  and  diaphragm,  ammonia  to  the 
nostrils,  slapping  the  chest  with  a  wet  towel, — also  may  be 
employed,  but  these  should  he  used  as  auxiliaries  to,  not  as  sub- 
stitutes for,  the  efforts  of  those  who  are  engaged  in  the  aerating 
process. 

The  question  which  may  next  occupy  our  attention  is,  whether 
there  are  any  known  conditions  of  the  systeni  in  which  nitrous 
oxide  is  contra-indicated. 

Pregnancy,  our  experience  informs  us,  is  no  barrier  to  its 
employment  ;  it  aj>pears  in  no  way  prejudicial  to  either  mother 
or  foetus.  [It  cannot  be  said  that  any  surgical  operation  is 
justifiable  during  pregniincy  exce}»t  under  the  most  pressing 
urgency,  when  delay  may  be  fraught  with  more  danger  than 
the  infliction  of  the  pain. 

In  this  connection,  attention  is  called  to  the  statement  in  the 
following  paragraph,  which  the  writer's  experience  contirms — ^ 

['  AnfestlieticsMedico-legall}'  Considered,  by  J.  G.  Johnson,  M.D.,  of  Brook- 
lyn, N.  Y.  See  Bulletin  of  the  Medico-Ijegal  Society  of  New  York,  vol.  iv. 
Nos.  7  and  8,  May-December,  1881.1 


336         MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

"1.  Antesthetics  do  stimulate  tlie-sexual  functions;  the  ano' 
genital  region  is  the  last  to  give  up  its  sensitiveness.  Charges 
made  by  females  under  the  influence  of  an  anaesthetic  should  be 
received  as  the  testimony  of  an  insane  person  is.  It  cannot  be 
rejected,  but  the  corpus  delicti  aUiuidi  rule  should  be  insisted  on. 
Dentists  or  surgeons  who  do  not  protect  themselves  by  having  a 
third  person  present,  do  not  merit  much  syrapath3\" 

"6.  Gross  violations  of  the  well-known  rules  of  administering 
anaesthetics,  life  being  lost  thereby,  will  subject  the  violator  to  a 
trial  on  the  charge  of  manslaughter." 

•'  8.  The  physician  who  administers  an  anaesthetic  should  at- 
tend to  that  part  of  the  work  and  nothing  else.  He  should  have 
carefully  examined  the  heart  and  lungs  beforehand.  He  should 
have  the  patient  in  the  reclining  position  with  his  clothes  loose, 
so  as  not  to  interfere  with  respiration  ;  should  have  his  rat-tooth 
forceps,  nitrite  of  amyl,  and  ammonia,  and  know  their  uses  and 
when  to  use  them  and  artificial  respiration."] 

Phthisical  patients  take  nitrous  oxide  fairly  well,  becoming 
angesthetized  with  less  gas  than  ordinary  patients,  as  we  should 
have  anticipated :  anaemic  patients  do  the  same. 

Patients  who  have  suffered  from  acute  rheumatism,  resulting 
in  damaged  valves  of  the  heart,  etc.,  appear  to  take  nitrous 
oxide  as  well  as  ordinary  patients,  but  the  appearance  of  a  lady 
affected  with  cyanosis  was  such  that  we  should  in  future  decline 
to  udminister  it  in  similar  cases.  Those  with  weak  and  fatty 
hearts  must  ever  be  unsafe  subjects  for  the  gas  or  other  anaes- 
thetics, though  probably  they  have  been  given  to  many  thou- 
sands of  such  unknowingly.  Should  we  have  a  knowledge  or 
suspicion  that  we  have  to  deal  with  a  patient  so  circumstanced, 
not  from  the  patient's  assertion,  for  nearly  half  of  the  patients 
to  whom  we  administer  nitrous  oxide  tell  us  that  they  believe 
tliere  is  sometliing  the  matter  with  their  hearts,  we  should, 
besides  redoubling  our  precautions  with  regard  to  careful  ob- 
servation of  all  symptoms,  pay  especial  attention  to  the  condi- 
tions of  the  pulse.  We  also  strongly  recommend  operating  only 
whilst  the  patient  is  fully  anaesthetized,  for  the  reason  that 
there  will  be  less  chance  of  arresting  the  heart's  action  through 
shock.  In  the  case  of  the  death  which  occurred  at  Exeter, 
closely  following  the  administration  of  nitrous  oxide,  an  upper 
molar  tooth  h:id  been  split  into  fragments  by  a  powerful  instru- 


ANiESTIIESTA, 


337 


ment  forced  into  its  pulp-cavity.  We  do  not  say  that  this  was 
the  cause  of  death,  yet  we  may  well  bear  in  mind  the  views  of 
Brunton  with  regard  to  shock  occurring  under  cliloroform 
administration.^ 

1  Through  the  kindness  of  our  colleague,  L.  Brunton,  we  are  enabled  to  pre- 
sent the  reader  with  the  views  of  that  gentleman,  illustrated  by  a  diagram  that 
he  has  prepared  for  us  (Fig.  299). 

Fig.  299. 


Vagus  centre  which  stops  the 

heart. 

Vaso-motor  centre  which  contracts 

the  arterioles. 


Vaso-motor  nerves. 


Diagram  illustrating  Lauder  Brunton's  views  of  the  cause  of  arrest  of  the  heart's  action  under 

chloroform  administration. 


"  The  blood,  when  it  reaches  the  veins,  is  useless  for  the  nutrition  of  the  tis- 
sues, as  we  see  in  a  corpse,  when  the  whole  of  the  blood  in  the  body  is  con- 
tained in  the  veins,  the  arteries  being  empty  :  only  so  long  as  it  is  in  the  arte- 
ries can  it  maintain  the  vitality  of  the  tissues.  The  blood  is  kept  in  the  arteries, 
1,  by  fresh  supplies  being  pumped  out  of  the  venous  system  into  the  arterial  by 
the  heart ;  3,  by  the  contraction  of  the  arterioles,  which  prevent  it  from  running 
back  too  quickly  into  the  veins. 

"  When  a  tooth  is  drawn  without  chloroform,  the  irritation  is  carried  by  the 
fifth  nerve  to  the  nerve-centres:  it  irritates  the  vagus  roots,  and  also  the  vaso- 
motor centre.  The  irritation  of  the  vagus  may  depress  or  arrest  the  heart's 
action  so  that  no  blood  is  sent  into  the  arterial  system  for  several  seconds  ; 
but  this  is  counterbalanced  by  the  irritation  of  the  vaso-motor  centre,  which 
causes  contraction  of  the  arterioles,  and  thus  correspondingly  diminishes  the 
outflow.  In  a  person  thoroughly  under  chloroform,  both  nerve-centres  have 
22 


338        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

Of  all  tlie  conditions  in  which,  according  to  our  opinion, 
nitrous  oxide  may  be  hurtful,  there  are  none  more  likely  to 
prove  so  than  where  a  patient  is  aft'ected  with  atheromatous  dis- 
ease of  the  cerebral  vessels,  upon  which  any  additional  strain, 
such  as  most  probably  occurs  during  its  inhalation,  would  be 
dangerous;  and  we  think  that  as  a  rule  it  would  be  well  to 
refuse  it  in  such  conditions. 

Independently  of  danger,  nitrous  oxide  may  be  attended  with 
very  disagreeable  after-conditions;  of  these  we  may  have  vomit- 
ing, and  vomiting  combined  with  syncope,  more  commonly,  as 
we  have  observed,  in  hot  weather.  In  one  or  two  cases,  a  lit- 
tle brandy  administered  previously  has  apparently  prevented 
these  unpleasant  results  in  some  who  on  former  occasions  had 
so  suffered.  A  prolonged  sleepy  condition,  much  as  if  the  pa- 
tient had  taken  a  powerful  narcotic,  is  occasionally  manifested  ; 
in  our  opinion  it  is  best  to  let  the  patient  sleep  this  off,  under 
guarded  observation.  Headache,  often  severe  and  lasting  longer 
than  the  day  of  administration,  is  not  uncommon  :  we  do  not 
know  that  we  can  suggest  better  remedies  than  rest,  quiet,  and 
patience.  Hysterical  females  will,  if  permitted,  often  give  much 
trouble,  and  the  patients  met  with  at  hospitals  heing  as  a  rule 
a  less  cultured  class,  and  therefore  less  under  intellectual  con- 
trol, will  be  found  the  worst;  we  need  hardly  say  that  the 
operator  will  by  sympath}^  only  encourage  such  exhibitions. 
Strange  sensations,  and  perversion  or  even  absence  of  ordinary 
sensations,  are  sometimes  complained  of  for  days  succeeding  an 
administration,  the  result,  no  doubt,  of  ciianges  from  which  the 
nervous  centres  have  suffered  owing  to  the  abnormal  condition 
of  the  blood  during  the  inhalation.     One  patient  has  informed 

tlieir  reflex  sensibility  abolished,  and  so  the  irritation  has  no  effect  on  either; 
but  with  partial  ansestliesia  the  vasomotor  centre  may  be  rendered  insensible 
before  the  vagus  centre,  and  consequently,  when  the  irritation  is  applied  to 
the  fifth  nerve,  the  vagus  centre  only  is  excited,  the  heart  is  depressed  or 
stopped,  and  the  inflow  of  blood  into  the  arterial  system  is  diminished  or 
arrested,  while  there  is  no  contraction  of  the  arterioles,  and  therefore  no  cor- 
responding diminution  of  the  outflow.  The  arterial  system  therefore  becomes 
more  or  less  empty,  i.  e.,  it  approaches  more  or  less  to  the  condition  of  death, 
and  fatal  syncope  may  result." 

With  nitrous  oxide,  however,  by  which  the  blood  in  the  arteries  is  brought 
into  a  venous  condition,  and  thus  acts  as  a  stimulus  to  the  vaso-motor  centre, 
the  danger  from  syncope  is  reduced  to  a  minimum. 


ANJESTIIESIA.  839 

U8  that  he  has  rletectcd  sugar  in  his  urine  after  eacli  iulialation 
of  nitrous  oxide, — an  interesting  fact,  if  it  be  at  all  general,  and 
pointing,  of  course,  to  cerebral  irritation. 

Before  we  quit  the  subject  of  nitrous  oxide,  we  would  give  a 
warning  with  respect  to  patients  inhaling  it,  especially  those 
pregnant,  with  other  than  moderately  empty  bladders;  otherwise 
there  is  risk  of  a  catastrophe  distressing  to  the  patient  and 
detrimental  to  an  elegantly  covered  chair. 

Ether,  although  no  doubt  a  much  safer  anfestlietic  than 
chloroform,  is  yet  probably  less  safe  than  nitrous  oxide.  Owing 
to  its  pungent  and  irritating  nature,  it  is  less  agreeable  to 
inhale  than  either  nitrous  oxide  or  chloroform;  but  this  may 
be  overcome  by  employing  it,  as  Clover  was  the  first  to  do,  viz., 
in  combination  with  nitrous  oxide.  It  requires  some  little 
practice  and  dexterity  to  administer  it  with  his  admirable  appa- 
ratus, but  with  that  which  we  have  described  (Fig.  294,  p.  o2T) 
it  only  needs  a  little  care  in  turning  the  ether  on  at  the  right 
period  ;  if  this  be  done  too  soon,  there  will  be  struggling,  and 
suspension  of  respiration;  if  too  late,  there  will  be  little  or  no 
benefit  from  the  ether  in  prolonging  the  anesthesia.  In  this 
matter  experience  alone  can  guide. 

Ether  with  nitrous  oxide  is  most  suitable  for  cases  in  which 
several  teeth  are  to  be  removed  at  one  sitting ;  we  think  it  also 
well  calculated  for  those  in  which  severe  after-pain  may  be 
anticipated,  as  in  a  tooth  giving  rise  to  alveolar  abscess  in  any 
of  its  stages,  recovery  being  less  sudden  than  with  nitrous  oxide 
alone. 

With  regard  to  sj-mptoms  indicating  danger,  these  will  be 
much  the  same  as  with  nitrous  oxide  alone,  though  perhaps  less 
apparent,  and  consequently  requiring  greater  watchfulness,  as 
with  ether  there  is  usually  less  lividity.  Whilst  the  respiration 
is  carefully  watched,  the  pulse  should  be  more  regarded  than 
with  nitrous  oxide.  In  employing  the  ether  combination  Ave 
must  look  for  more  tendency  to  vomiting.  This  is  a  most  un- 
pleasant drawback  to  the  use  of  anaesthetics,  and  therefore  one 
of  the  greatest  merits  of  nitrous  oxide  is  that  it  is  the  most 
free  from  it.  With  regard  to  ether  versus  chloroform,  the  latter 
has  been  reckoned  by  Jonathan  Hutchinson  as  the  safer  for 
very  old  people,  there  being  less  violent  struggling,  and  con- 
sequently less  exhaustion  ;  but  this  must  apply  to  ether  adminis- 


340    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

tered  alone,  as,  with  the  nitrous  oxide  combination,  when  care- 
fully administered,  there  is  probably  less  strug;glin^  than  under 
any  other  method.  Chloroform  is  preferable  to  ether  in  the  case 
of  patients  suffering  from  bronchitis. 

The  administration  of  chloroform  in  dental  operations  has 
now,  and  most  properly,  become  so  exceptional  a  matter  that 
we  need  devote  but  a  short  space  to  its  consideration  ;  there  are, 
however,  a  few  rare  cases  in  which  it  is  preferable  to  other 
anaesthetics.  Thus  we  find  instances  of  patients  who  recover  so 
rapidly  from  nitrous  oxide,  or  its  combination  with  ether,  that 
it  is  hardly  possible  to  remove  one  tooth  or  root  without  pain 
being  felt,  and  such  patients  may  require  the  removal  of  a  large 
number  of  either. 

In  cases  when  great  muscular  contraction  has  to  be  overcome, 
as  with  impacted  wisdom  teeth,  chloroform  will  be  generally 
preferred ;  although  our  colleague,  J.  Mills,  of  St.  Bartholo- 
mew's, informs  us  that  in  the  reduction  of  dislocations  he  has 
found  ether  almost,  if  not  quite,  as  efficacious  as  chloroform. 
In  the  cases  bordering  on  the  limits  between  dental  and  general 
surgery,  such  as  the  removal  of  epulis  and  kindred  tumors,  the 
dissecting  out  of  cicatrices,  and  other  operations  which  must 
occu[>y  some  time  in  their  performance,  and  where  the  anaesthe- 
sia has  to  be  kept  up  during  the  period,  chloroform  will  no 
doubt  be  generally  preferred. 

As  to  the  modes  of  administration,  we  doubt  whether  there 
is  any  one  vastly  superior  to  another.  The  Scotch  school  have, 
as  a  rule,  performed  it  in  the  simplest  manner  and  without 
apparatus,  and  with,  we  believe,  as  much,  if  not  more,  success 
than  in  England,  where  apparatus  has  been  more  generally  em- 
ployed. Our  conclusion  has  long  been,  that  safety  depends  far 
more  upon  the  experience  and  judgment  of  the  administrator 
than  ui)on  the  mode  of  administration  ;  and  we  need  here  hardly 
remark,  that,  if  it  be  an  unwarrantable  assumption  of  respon- 
sibility to  administer  single-handed  nitrous  oxide  for  a  dental 
operation,  it  is  absolutely  criminal  to  do  so  with  chloroform. 
Practitioners  are  often  pressed  by  patients  to  give  it  to  them, 
with  such  assurances  as  "  I  take  chloroform  so  well,  my  maid 
often  gives  it  to  me,"  etc.  A  wise  practitioner,  some  little  time 
since,  saved  himself  from  an  awful  reaponsibility,  as  the  patient 
who  so  requested  him  subsequently  died  under  the  hands  of  an 


ANAESTHESIA. 


341 


experienced  anaesthetist.  With  regard  to  chloroform-inhalers, 
and  their  name  is  legion,  we  must  undoubtedly  pronounce  the 
most  perfect  to  be  that  devised  so  ingeniously  by  Clover,  on 
the  suggestion  of  Snow,  in  wliich  definite  proportions  of  the 


Fie.  300. 


Tho  author's  chloroform  apparatus,  consisting  of  a  graduated  drop-bottle  which  contains  the 
chloroform,  and  which  can  be,  by  turning  it,  inverted  so  that  the  fluid  drops  on  to  a  piece  of 
sponge.  The  expanded  portion  has  in  front  of  it  a  piece  of  fine  wire  gauze,  which  has  tho  object 
of  thoroughly  mixing  the  chloi'oform-vapor  and  air  together,  rendering  the  vapor  less  pungent. 

vapor  and  air  are  previously  mixed  together ;  its  only  objection 
is  its  somewhat  formidable  appearance,  which  may  terrify  some 

Tin:.  301. 


Apparatus  figured  in  300  with  a  nose  piece  for  keeping  up  the  ana;sthesia 
whilst  the  mouth  is  open. 

very   nervous  persons  =or   children,  a  condition  always  to  be 
avoided,  as  adding  another  element  of  danger,  viz.,  the  depres- 


342    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

sion  consequent  on  fear;  but  it  must  be  remembered  tbat 
the  process  can  always  be  commenced  with  the  lint  and  the 
drop-bottle,  and  maintained  afterwards  by  the  apparatus.  An 
inhaler  which  we  dt^vised  some  years  ago  (Figs.  300,  301) 
combines  the  drop-bottle  with  a  very  simple  apparatus,  like  the 


Fio;.  o02. 


The  author's  apparatus  for  adiniuistering  chloroform  through  the  nose  The  small  tubes'are 
inserted  into  the  naros,  and  air  is  pumppd  through  the  iuhaler  by  rneaus  of  the  ludia-rubber 
syringe,  the  small  holes  opening  into  the  inhaler  being  closed  by  the  thumb. 


Fii?.  303. 


A  form  of  chair-couch  very  convenient  for  ojierations  upon  the  mouth  under  chloroform. 

smaller  one  of  Snow,  but   liaving  an   arrangement    for   more 
thoroughly   mixing  the  vapor  with  air,  which  renders  a  deep 


ANiESTHESIA. 


343 


inspiration  free  from  the  otherwise  disacrreeable  irritating  sen- 
sation 80  conspicuously  absent  in'  the  Clover  apparatus.  For 
keeping  up  the  anaesthesia  we  have  employed  an  India-rubber 
air-propeller  (Fig.  302)  attached  to  an  a{)paratus,  by  which  means 
air  impregnated  with  chloroform  is  forced  into  the  nares ;  but, 
unpleasant  symptoms  having  occurred  under  our  own  hands, 
and  those  of  others,  when  em[)loying  similar  arrangements,  we 
suggest  that  it  should  be  used  with  the  greatest  caution.  With 
regard  to  the  symptoms  of  danger  and  the  best  methods  of 
averting  or  counteracting  them — the  latter  of  which  are,  un- 
fortunately, by  no  means  generally  decided  upon  at  })resent — 
we  must  refer  the  reader  to  works  specially  devoted  to  the 
subject.^ 

1  In  operating  upon  patients  under  the  influence  of  chloroform  it  is  very  de- 
sirable that  they  should  be,  as  far  as  possible,  placed  in  the  recumbent  posture, 
and,  were  it  much  employed  in  dental  surgery,  the  chair  above  figured  (Fig. 
303),  which  permits  this,  would  be  found  of  much  service. 

[The  ordinary  dental  chair  should,  as  in  tlie  S.  S.   W.  chair,  Fig.  304,  be 


Fig.  304. 


The  S.  S.  White  pedal  lever  chair. 


344    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

We  have  refrained  from  alluding  to  other  and  less  gene- 
rally emploj'ed  antesthetics  than  those  mentioned  above,  such 
as  bichloride  of  mj^thelene,  bromide  of  ethyl,  ethidene-dichlo- 
ride,  etc.,  on  the  ground  of  their  not  having  been  employed 
extensivelj^  or  often  enough  to  enable  us  to  speak  of  their  com- 
parative safety.  The  last-mentioned  agent  appears,  from  the 
experiments  performed  by  a  committee  of  the  British  Medical 
Association,  to  hold  a  position  as  regards  safety  between  chloro- 
form and  ether.  In  flavor  it  is  much  more  pleasant  than  the 
latter;  and  our  experience  in  it  leads  us  to  think  that  it  may 
become  a  favorite  and  useful  anfesthetic  in  dental  surgery. 

capable  of  letting  the  patient  down  to  a  reclining  position,  and  in  extreme 
anaemia  the  feet  may  witli  advantage  be  raised  higher  than  the  head,  to  promote 
gravitation  of  blood  to  the  brain.  ] 


REPLANTATION  AND  TRANSPLANTATION  OF  TEETH.   345 


CHAPTER  XVI  I. 

THE  REPLANTATION  AND  TRANSPLANTATION  OF  TEETH. 

Replantation. — The  operation,  either  of  restoring  dislocated 
teeth  to  their  sockets,  or  of  extracting  thera  on  account  of  pain 
and  then  replacing  them,  appears  to  have  been  practised  several 
centuries  ago. 

We  find,  in  an  excellent  paper  on  this  subject  and  that  of 
transplantation,  by  A.  Mitscherlich,'  that  Dupont,  in  1633,  ex- 
tracted and  re[)lanted  a  tooth  on  account  of  violent  pain,  and 
that  it  became  firmly  attached  ;  subsequently  Dion  Pomaret 
states  that  he  had  witnessed  a  successful  result  of  the  same  pro- 
cess ;  and  about  a  century  later  Fauchard  speaks  of  it  as  a  fact 
quite  well  known,  and  wonders  that  any  one  can  still  doubt  of 
its  practicability,  and  mentions  cases  in  his  own  practice,  five 
in  all,  in  two  of  which  he  filled  the  teeth  some  time  afterwards, 
in  order  to  make  them  durable. 

In  Germany,  replantation  was  practised  at  the  commencement 
of  the  eighteenth  century,  especially  for  cases  where  teeth  could 
not  be  properly  filled  in  the  mouth ;  they  were  extracted,  tilled, 
and  re|ilaced. 

In  France,  L'Ecluse  and  Bourdet  were,  about  the  middle  of 
the  same  century,  great  promoters  of  replantation  for  the  same 
object,  and  the  latter  extracted  a  fang,  fastened  to  it  a  pivot- 
tooth,  and  reinserted  it,  and  after  five  and  a  half  years  it  was 
still  firm. 

In  England,  Hunter  about  the  same  period  interested  himself 
in  the  subject,  but  never  appears  to  have  given  the  same  atten- 
tion to  it  as  he  did  to  transplantation. 

From  Hunter's  time  to  the  present,  the  operation  of  replanta- 
tion, for  teeth  which  have  been  knocked  out  of  their  sockets,  or 

'  Langenbeck's  Archiv  fiir  Cliirurgie,  vol.  iv.     Translated  into  English  in 
the  Archives  of  Dentistry,  by  Edwin  Truman,  vol.  i.  p.  169. 


346    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

extracted  by  mistake,  has  been  continuously  performed;  and, 
exceptionally,  in  cases  where  intense  pain  has  existed,  and  also 
where  a  filling  could  not  without  great  difficulty  be  performed 
in  the  mouth. 

In  speaking  of  the  operation,  almost  all,  if  not  all,  who  have 
written  upon  the  subject  lay  down  the  rule  that  it  is  never  to 
be  attempted  with  teeth  the  roots  of  which  are  diseased.  Hun- 
ter, while  strongly  enforcing  this  opinion,  yet  admits,  "  to  ex- 
tract the  tooth  and  then  to  tile  off  any  diseased  part  of  it,  and 
immediately  to  replace  it,  has  been  practised,  but  often  without 
the  desired  success ;  for  it  has  often  happened  that  a  tooth  has 
been  introduced  into  a  diseased  jaw.  This  practice,  however, 
has  now  and  then  succeeded." 

Hunter  certainly  does  not  advocate  it;  and  Mitscherlich,  evi- 
dently summing  up  the  opinions  of  those  wlio  have  gone  before' 
him,  as  well  as  expressing  his  own,  says,  "  Teeth  whose  roots 
are  diseased  are  always  to  be  removed,  and  must  not  be  inserted, 
as  they  cannot,  from  grounds  to  be  given  later,  again  become 
united."! 

It  can  scarcely,  we  think,  be  stated  that  replantation,  as  a 
systematic  treatment  for  chronic  periodontitis,  was  ever  advo- 
cated until  the  appearance  of  two  papers  which  we  read  before 
the  Odontological  Society  in  1869  and  1870.  In  speaking 
therein  of  that  most  intractable  of  diseases,  and  its  almost  uni- 
versal treatment  by  extraction,  we  pointed  out,  that  by  the  re- 
moval of  a  tooth  so  affected,  the  careful  scraping  from  its  fangs 
of  diseased  membranes,  the  clearing  out,  purifying,  and  then 
filling  of  its  pulp  and  fang  cavities,  and  then,  after  washing  it 
as  well  as  its  alveolus  with  an  antiseptic  fluid,  returning  it  to 
its  socket,  we  might  hope  to  preserve  it  as  a  useful  member,  and 
we  gave  a  statement  of  fourteen  cases  in  which  this  treatment 
had  been  adopted,  but  upon  its  ultimate  success  it  was  at  that 
period  too  early  to  offer  any  opinion. 

'  In  A  System  of  Dental  Surgery,  by  Jolin  Tomes,  F.R.S.,  and  C.  S.  Tomes, 
M.A.,  p.  658,  the  following  is  stated  :  "  It  sliould  have  been  mentioned  in  the 
section  relating  to  alveolar  abscess  that  experiments  have  lately  been  performed 
by  Mr.  Coleman,  following  in  the  steps  of  Mitscherlich  and  others,  in  which 
carious  teeth  were  extracted  and  replaced,  after  scraping  off  the  thickened 
and  diseased  periosteum."  "We  tliink  that  tlic  words  wiiich  we  have  put  in 
italics  should  more  properly  have  been  rendered  "in  opposition  to  the  views  of 
Mitscherlich  and  others." 


REPLANTATION    AND    TRANSPLANTATION    OF    TEETH.       347 

Since  the  |)ul)lication  of  our  papers,  the  subject  lias  excited 
much  interest  and  attention  l)Othon  tlie  Continent  and  in  America. 
Magitot  has  brought  it  under  the  attention  of  the  Academy  of 
Sciences  of  Paris,  and  his  papers  upon  it  have  been  published  in 
the  "Comptes  Rendus,"and  the  "Bulletins  et  M^nioiresde  la  So- 
ciete  de  Chirurgie."  In  the  latter  the  treatment  of  sixty-three 
cases  is  recorded,  out  of  which  only  five,  at  the  time  wiien  the 
paper  was  written,  had  turned  out  failures.  Magitot's  success, 
so  much  greater  than  our  own  in  a  more  limited  number  of  cases, 
may  be  due  to  his  metiiod  of  procedure,  which  consists  in 
simply  excising  the  denuded  jiortion  of  the  fang, — tilling  the 
tooth,  of  course,  if  necessary, — and  returning  it  without  applica- 
tion of  antiseptic  to  either  the  root  or  the  alveolus.  As  in  our 
own  recommendations,  he  has  seldom  found  it  necessary  to  retain 
the  tooth  in  its  socket  either  by  ligature  to  adjacent  teeth  or 
by  mechanical  appliance.  He  also  deems  it  most  iniportant  to 
maintain  a  free  drainage  from  the  alveolus,  especially  in  the 
severer  cases.  The  success  of  the  operation  he  considers  to  be 
entirely  dependent  u[)on  the  existence  of  a  complete  ring  of  heal- 
thy periodontium  on  the  tooth  to  be  replanted. 

We  have  preferred  alluding,  thougli  in  general  terms,  to  the 
methods  adopted  by  Magitot  rather  than  to  our  own,  as  both  his 
experience  and  success  have  been  greater;  also  because  we  must 
go  over  much  the  same  ground  in  treating  upon  our  second 
head,  viz  .Transplantation. 

Transplantation. — This  operation  appears  to  have  been  per- 
formed at  an  earlier  period  than  that  which  we  have  just  con- 
sidered. Some  have  attributed  its  origin  to  Abulcasis  (died 
1122),  but  the  passage  quoted  in  favor  of  this  supposition  refers 
more  probably  to  the  tixing  of  an  artificial  tooth.  Ambrose  Pare, 
however,  records  a  case  where  a  young  princess  had  a  sound  tooth 
of  her  waiting-maid  inserted  in  the  place  of  a  carious  one  ex- 
tracted, and  with  a  successful  result.  Nothing,  however,  appears 
to  have  been  done  in  this  direction  for  some  150  years,  until  the 
operation  was  resuscitated  by  Fauchard,  and  with  much  greater 
zeal  by  Bourdet,  who  appears  to  have  obtained  his  teeth  for 
transplanting  from  Savoyard  boys,  whose  great  poverty  induces 
them  to  be  thus  victimized. 

The  operation  of  transplantation  found  considerable  favor  in 
the  eyes  of  Hunter,  Plfaf,  Graebner,  Richter,  Jourdain,  and  some 


348    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

others;  but  it  had  many  strong  opponents,  even  more  so  than  in 
the  ease  of  replantation.  The  chief  arguments  employed  against 
the  operation  were,  as  we  pointed  out  some  years  ago,^  the  three 
following,  viz.,  1.  Liability  to  failure;  2.  Chance  of  inoculation 
of  disease ;  3.  The  moral  objection. 

1.  Liability  to  failure. — This  is  considerable,  and  may  arise 
from  the  so-called  scion-tooth  not  being,  from  its  size,  form  of 
fang,  or  injury  occurring  to  it  in  its  removal,  etc.,  adaptable  to 
the  socket  of  the  tooth  which  it  is  intended  to  supplant.  Also, 
when  the  above-mentioned  conditions  are  not  unfavorable,  it 
often  happens  that  the  scion-tooth  is  implanted  in  an  alveolus 
more  or  less  diseased  from  the  long  existence  of  a  necrosed  tooth. 
Pain  and  tenderness  are  for  some  days  a  common  sequence  to 
the  operation,  and  even  under  favorable  circumstances  are  often 
severe;  and,  the  tooth  being  very  loose,  the  patient  is  tempted 
to  obtain  relief  by  removing  it.  The  method  also  commonly 
employed  of  attempting  to  secure  the  transplanted  tooth  to  ad- 
jacent ones  by  means  of  ligature  was,  as  we  think  we  shall  be 
able  to  show,  another  very  probable  cause  of  failure. 

2.  Chance  of  inoeulatio?i  of  disease. — This  we  believe  to  have 
been  much  more  imaginary  than  real,  although  it  cannot  be 
denied  that  there  might  be  a  chance  of  transferring,  with  a 
tooth  removed  from  a  person  at  a  certain  stage  of  the  disease, 
such  afiections  as  syphilis,  smallpox,  scarlatina,  measles,  etc. ; 
and  the  same  objection  would  apply  in  an  equal  degree  to  skin- 
grafting  from  one  person  to  another,  as  well  as  to  several  other 
surgical  proceedings.  We  are  inclined,  however,  to  believe  that 
this  argument  was  employed  rather  to  deter  and  dissuade  per- 
sons from  undergoing  an  ojjeration  so  properly  discontinued  on 
the  ground  of — 

3.  T7ie  moral  objection. — That  the  poor  and  generally  degraded 
should  have  been  induced  by  a  pecuniary  temptation  to  part 
with  organs  as  essential,  or  probably  even  more  essential,  to 
their  well-being  than  the  wealthy  coveters  who  could  purchase 
them,  became,  and  rightly  so,  to  be  regarded  as  an  injustice  and 
a  wrong.  A  much  greater  skill  and  success  in  saving  defective 
teeth,  and  in  supplying  artificially  their  place  when  lost,  no 

'  On  tlie  Transplantation  of  Teeth,  by  Alfred  Coleman.  St.  Bartholomew's 
Hospital  Reports,  vol.  xiv.  p.  101. 


REPLANTATION    AND    TRANSPLANTATION    OF    TEEEII.       B49 

doubt  also,  to  a  very  great  extent,  diverted  attention  from  the 
operation  of  transplantation. 

The  success  that  attended  our  experiments  in  replantation, 
though  not  very  encouraging,  determined  us  nevertheless  to 
attempt  that  of  transplantation,  but  under  conditions  wholly 
free  from  the  moral  objection  above  stated. 

It  has  been  pointed  out  in  previous  pages  (see  Chapter  TV.) 
that  amongst  civilized  nations  the  maxillae  of  the  present  gene- 
ration are  of  smaller  size  than  they  were  in  people  who  lived 
some  centuries  ago  ;  whilst  the  teeth,  if  thej^  have  diminished 
in  size,  have  not  done  so  in  the  same  proportion,  and  thus  occur 
crowding  and  irregularity  in  position  of  the  latter.  The  dental 
surgeon  is  often  called  upon  to  correct  this  by  the  removal  of 
sound  teeth,  and  that  these  young  and  healthy  teeth  should  be 
east  away  as  useless,  whilst  there  were  so  many  for  whom  the 
operation  of  transplantation,  if  successfully  performed,  would 
be  the  greatest  boon,  appeared  to  us  a  sad  misfortune. 

We  have,  therefore,  from  time  to  time  during  the  last  six 
years  performed  the  operation  of  transplanting  teeth  from  the 
mouths  of  those  who  had  to  part  with  them  through  over- 
crowding to  the  mouths  of  those  from  whom  they  were  removed 
on  account  of  disease,  and  with  a  much  greater  proportionate 
success  than  in  the  operation  of  replantation  for  the  cure  of 
periodontitis.  We  have  performed  it  on  at  least  twelve  occa- 
sions, and  we  believe  with  only  two  failures,  both  resulting 
from  the  tooth  not  being  adaptable  to  its  new  habitation.  Be- 
sides these  cases,  it  has  been  performed  by  others  under  our  ob- 
servation some  fifteen  times,  not,  we  believe,  with  quite  the 
same  success,  as  the  cases  were  probably  not  so  carefully  selected. 
Our  first  case,  that  of  a  medical  student,  in  1875,  for  whom  a 
right  lateral  incisor  was  thus  supplied,  was,  when  last  heard  of, 
about  a  year  ago,  perfectly  satisfactory.  In  two  of  the  cases  we 
transplanted  misplaced  laterals  to  alveoli  on  the  opposite  side  in 
the  same  patients,  and  were  successful.  In  another  case,  that 
of  a  youth  aged  sixteen,  two  upper  laterals  were  transplanted 
from  another  subject  with  perfect  success. 

The  operation,  which  we  always  conducted  under  an  anaesthe- 
tic, was  thus  performed.  The  individual  to  receive  was  operated 
upon  first,  every  care  being  taken  in  the  removal  of  the  tooth  or 
root  to  injure  the  alveolus  as  little  as  possible;  the  mouth  was 


350    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

■waslied  out  with  tepid  water  until  bleeding  had  nearly  ceased. 
The  patient  to  contribute  was  then  operated  on,  and,  his  tooth 
being  also  carefully  extracted,  it  was  carried  directly  to  the 
former,  and  firn)ly  pressed  into  the  vacant  alveolus,  after  clear- 
ing out  the  same,  first  v»'ith  cotton-wool  and  then  with  the 
syringe,  the  finger  and  thumb  onl}^  being  employed.  In  no  in- 
stance was  any  ligature  employed,  this  being  in  our  opinion 
more  likely  to  prove  mischievous  than  beneficial,  and  for  the 
following  reason.  The  tooth,  however  firmly  pressed  into  the 
socket,  soon  becomes  slightly  raised  from  it  by  effusion  into  the 
latter,  which  causes  it  also  to  be  more  or  less  loose.  'Now  this 
effusion  has  no  douI)t  much  to  do  with  the  future  union  of  the 
tooth  and  alveolus,  through  the  medium  of  the  alveolo-dental 
membrane;  and  to  prevent  this  efi'usion,  as  must  be  the  case  to 
a  great  extent  when  the  tooth  is  firmly  tied  into  the  socket,  is 
to  interfere  with  the  process  of  attachment.  Moreover,  we  are 
strongly  inclined  to  attribute  to  this  procedure  those  untoward 
results,  viz.,  severe  inflammation,  abscess,  necrosis  of  alveoli, 
etc.,  which  have  been  spoken  of  by  former  writers  as  not  unfre- 
quentl}'  following  this  operation,  but  which  we  have  never  met 
with.  After  having  implanted  the  tooth,  we  have  simply 
directed  the  patient  to  carefully  avoid  masticating  upon,  or 
touching  it  with,  the  opposing  ones  for  some  days,  and  to  em- 
ploy soothing  fomentation  to  relieve  any  tenderness.  There 
could  be  no  objection  to  construct,  previously  to  the  operation, 
a  plate  that  would  protect  the  tooth  from  any  violence  or  pres- 
sure. 

In  some  cases  a  week  only  has  sufficed  to  allow  the  tooth  to 
becorrie  moderately  firm,  free  from  tenderness,  and  even  capable 
of  bearing  a  certain  amount  of  pressure;  but  a  fortnight  has 
more  commonly  been  required.  A  point  of  no  small  importance 
is,  to  select  for  transplantation,  if  possible,  teeth  the  fangs  of 
which  are  rather  less  in  dimensions  than  those  for  which  they 
are  to  be  substituted.  When  transplanted  tliey  may  not  appear 
so  firm  as  larger  ones,  but  in  the  end  the^^  become  so.  In  our 
practice,  lateral  incisors  inserted  into  the  alveoli  of  centrals  and 
cuspidati  have  turned  out  very  successful.  In  speaking  of  the 
transplantation  of  teeth,  which,  under  the  conditions  spoken 
of,  may,  we  consider,  from  our  experience  of  it,  be  recom- 
mended as  a  useful  and  iierfectly  legitinmte  operation,  we  may 


REPLANTATION  AND  TRANSPLANTATION  OF  TEETH.   351 

repeat  what  we  have  elsewhere  written.'  "  I  am  in  hopes  that 
having  called  attention  to  the  operation  and  its  merits,  it  may 
be  the  means  of  conferrinor  much  benefit,  especially  upon  a  class 
whose  pecuniary  circumstances  prevent  them  from  attainins: 
comforts  which  their  more  affluent  neighbors  can  well  afford. 
I  cannot  but  believe  that  with  our  dental  departments  and 
dental  hospitals,  at  which  so  many  thousands  of  young  and 
henlthy  teeth  are  annually  sacrificed,  these  might  be  turned  to 
profitable  account,  and  by  selection  of  suitable  cases  out  of  large 
numbers,  the  operation  of  transplantation  might  be  again  re- 
garded as  legitimate  and  useful." 

Before  concluding  this  chapter,  we  must  say  a  few  words 
upon  the  transplantation  of  dead,  or  rather  dried,  teeth,  such  as 
have  usually  been  obtained  from  the  corpse.  This  operation 
has,  like  the  same  process  with  living  teeth,  had  its  advocates 
and  its  opponents.  The  former  evidently,  as  shown  by  the  con- 
tradictory nature  of  their  statements,  have  been  prejudiced  and 
partial  with  regard  to  it.  Hunter,  who  describes  the  process  at 
some  length,  says:  "The  insertion  of  a  dead  tooth  has  been 
recommended,  and  I  have  known  them  to  continue  many  years;" 
whereas  in  another  place  he  says:  "  A  tooth  which  has  been 
extracted  for  some  time,  so  as  to  lose  the  whole  of  its  life,  will 
never  become  firm  or  fixed."  Hirsch,  another  advocate,  in  like 
manner  contradicts  himself. 

That  such  an  operation  should,  as  a  rule,  prove  unsuccessful, 
is  what  we  could  but  anticipate.  A  tooth  long  removed  from 
the  mouth,  and  dried,  would  not  only  be  entirely  devoid  of 
vitality  in  all  its  structures,  but  w^ould  have  lost  all  medium  for 
uniting  those  devitalized  tissues  to  adjacent  living  ones.  The 
fact  that  some  of  the  dental  structures,  for  instance  the  dentine, 
pulp,  and  enamel — i.  e.,  if  it  possess  any — had  lost  their  vitality, 
would  not,  as  we  have  elsewhere  shown,  if  they  be  free  from 
putridity  and  sei>ticity,  be  a  barrier  to  a  tooth  being  trans- 
planted, provided  that  the  cementum  and  remains  of  the  al  veolo- 
dental  membrane  retained  theirs,  as  they  frequently  do  under 
such  conditions.  Where  all  the  structures  are  devoid  of  vitality, 
w^e  should  expect  such  teeth,  if  at  all  retained,  to  be  so  simply 
mechanically,  and  never  to  become  firm,  or  more  probably  to 

'  Op.  cit. 


352    MANUAL  OF  DENTAL  SORGERY  AND  PATHOLOGY. 

share  the  same  fate  as  do  ivorj  pegs  when  inserted  into  bone, 
viz.,  to  be  absorbed.  But  that  such  teeth  when  inserted  have 
in  rare  instances  undoubtedly  become  perfectly  firm,  indeed  so 
much  so  as  to  present  the  greatest  resistance  to  their  removal, 
needs  some  further  explanation,  and  this  is  satisfactorily  fur- 
nished in  the  experiments  of  Mitscherlich,  recorded  in  the  ex- 
cellent paper  before  referred  to. 

He  took  an  upper  incisor  from  a  dog's  skull,  and  inserted  it 
into  the  corresponding  alveolus  of  a  living  dog,  which  he  killed 
after  six  weeks,  and  then  he  immediately  injected  the  carotids. 
A  longitudinal  section,  made  through  the  tooth  and  jaw,  showed 
the  periosteum  to  be  discoverable  in  only  a  few  places :  where 
this  was  absent,  the  tooth  was  eaten  away.  In  some  of  the 
cavities  thus  formed,  osseous  tissue  directly  connected  with  the 
'^  alveolar  processes  existed,  and  so  held  the  tooth  with  such  ex- 
traordinary firmness ;"  and  into  this  the  injection  had  readily 
passed.  He  says,  "  It  was  so  fully  developed,  that  the  process 
had  to  be  looked  upon  as  fully  accomplished,  and  therefore  a 
later  exfoliation  of  the  tooth  was  not  to  be  expected."  We 
think  the  latter  sentence  expressed  in  too  confident  terms.  The 
researches  of  J.  Tomes,  already  referred  to,  with  regard  to  the 
absorption  of  temporary  teeth,  show  a  very  similar  condition 
prevailing  at  times,  viz.,  w^here  the  dentine  in  such  teeth  is  di- 
rectly connected  at  certain  parts  with  osseous  tissue  which  again 
becomes  absorbed.  On  the  other  hand,  we  may  point  out  that 
in  our  examination  of  the  teeth  found  in  ovarian  tumors  some 
have  been  met  with  directly  united  to  surrounding  bone  with- 
out any  intermediate  tissue. 

Finally,  attempts  have  been  made  to  insert  porcelain  teeth, 
and  even  teeth  having  fangs  composed  of  gold,  into  alveoli,  and 
with  the  success  that  we  should  naturally  have  expected ;  and 
w^e  may  conclude  our  remarks  upon  the  process  of  transplanta- 
tion by  observing,  that  to  insure  a  fair  amount  of  success  the 
operation  must  be  conducted  with  living  teeth,  obtained  from 
individuals  under  middle  age,  and  inserted  into  the  mouths  of 
those  not  past  middle  age,  which  must  be  fairly  healthy,  and 
free  from  tiie  existence,  to  any  extent,  of  alveolar  mischief.  [The 
writer  has  suggested  the  use  of  living  teeth  from  the  lower  ani- 
mals, as  justifiable  and  probably  practicable  for  transplantation.] 


CONGESTION    OF    THE    GUMS.  353 


CHAPTER    XVIII. 

CONGESTION  OF  THE  GUMS— SALIVARY  CALCULUS— ULCERA- 
TIONS OF  THE  GUM— NECROSIS  OF  THE  JAWS. 

Congestion  of  the  Gums. — The  mucous  membrane  covering, 
and  included  in  the  structures  called  the  gums,  should  in  the 
healthy  subject  be  of  a  pale  rose-color,  marbled  by  minute  ves- 
sels of  a  rather  darker  tint,  presenting  around  the  teeth  a  fes- 
tooned edge  as  thin  as  ordinary  writing-paper,  and  appearing  to 
be  firmly  attached  to  the  necks  of  the  teeth,  but  in  reality  at- 
tached a  little  distance  off,  being  folded  down  to  the  cementum, 
where  it  becomes  intimately  blended  with  the  alveolo-dental 
membrane.  The  interstices  between  the  teeth,  at  and  near  to 
their  necks,  should  also  in  the  healthy  subject  be  fully  occupied 
by  the  same  structures,  rendering  it  scarcely  possible  for  food  to 
become  lodged  there.  In  highly  civilized  communities,  and 
especially  amongst  the  denizens  of  large  cities,  we  not  uncom- 
monly find  the  structures  in  question,  without  actually  exhibit- 
ing disease,  of  a  darker  color,  thicker  texture,  and  not  fully 
occupying  the  spaces  between  the  necks  of  the  teeth.  Amongst 
dyspeptic  persons  such  conditions  are  generally  seen  in  an  ex- 
aggerated form,  whilst  many  of  the  worst  cases  are  those  met 
with  in  the  subjects  of  glandular  struma:  from  the  constant 
tendency  of  the  gums  to  bleed,  this  has  been  termed  false  scurvy, 
or  scurvy  of  the  gums.  Under  the  latter  conditions  the  mucous 
membrane,  especially  that  adjacent  to  the  teeth,  appears  deeply 
congested  with  venous  blood,  tumid  and  thickened,  but  not 
filling  up  the  interstices  at  their  necks,  and  detached,  for  some 
distance  from  the  surface,  from  the  fangs.  A  thick  fetid  dis- 
charge may  often  be  pressed  up  between  the  teeth  and  mucous 
membrane,  which  gives  to  the  breath  a  very  repulsive  odor. 
This  condition  of  things  continuing,  the  alveoli  become  ab- 
sorbed and  at  times  more  or  less  denuded,  whilst  the  fangs  of 
the  teeth  become  coated  with  a  layer  of  thin  hard  greenish-brown 
tartar.     Ultimatel}',  the  disease  progressing,  the  teeth  one  after 

23 


354    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

another  drop  out.  The  loss  of  the  teeth  by  alveolar  absorption, 
if  not  a  natural  order  of  things,  is,  at  least  in  very  old  age,  <in 
event  generally  looked  for,  as  much  so  as  is  the  loss  of  hair 
from  the  head.  When  occurring  prematurely,  and  in  connection 
with  the  condition  of  mucous  membrane  above  described,  it 
certainly  constitutes  a  disease,  and  a  very  refractory  one  to  deal 
with.  Authorities  difier  much  as  to  both  its  cause  and  its 
nature :  some  attribute  it  wholly  to  local  causes,  notably  to 
neglect  in  cleansing  the  teeth  and  permitting  tartar  to  accumu- 
late about  their  necks ;  others  believe  that  it  has  its  origin  in 
the  alveolo-dental  membrane;  and  some,  C.  S.  Tomes  in  parti- 
cular, that  the  structure  first  affected  is  tlie  alveolar  process  at  its 
free  edges.  Our  own  views  accord  most  with  those  who  maintain 
that  it  arises  from  an  unhealthy  condition  in  the  mucous  mem- 
hrane  in  the  neighborhood  of  the  necks  of  the  teeth.  This  may 
be  the  result  of  constitutional  conditions  before  alluded  to,  or  it 
may  and  probably  does  arise  from  the  want  of  a  due  stimulus  to 
the  mucous  membrane  supplied  in  the  form  of  harder  food  than 
that  which  civilized  nations  as  a  rule  consume.  The  presence 
of  tartar  may  no  doubt  increase  and  aggravate  it,  but  we  see 
cases  where  this  deposit  has  existed  for  man}'  years  without 
producing  such  results.  The  very  conditions  of  its  existence 
tend  to  increase  and  perpetuate  it;  friction  by  brushing,  rub- 
bing, etc.,  being  avoided  on  account  of  the  pain  experienced. 
The  congestion  and  separation  of  the  gum  at  the  necks  of  the 
teeth  permit  the  access  of  the  fluids  of  the  mouth,  and  the  for- 
mation of  tartar,  modified  in  character  probably  by  the  acid 
mucus  furnished  by  tlie  gum,  and  adhering  most  firmly  to  the 
roots  of  the  teeth.  As  the  separation  extends,  the  free  edges 
of  the  alveoli  become  denuded,  and  consequently  suti:er  a  slight 
necrosis,  perhaps  most  comparable  to  caries,  but  on  a  very  small 
scale. 

In  this,  which  may  be  deemed  its  acute  form,  it  is  most 
common  about  the  middle  period  of  life,  3'et  we  have  met  with 
it  in  iiidividuals  under  twent3\  It  must  not  be  confounded 
with  a  [>reniature  loss  of  the  teeth,  as  occasionally  witnessed  in 
individuals  who  have  suffered  severely  from  debilitating  ill- 
nesses ;  when  they  thus  come  out,  they  are  free,  or  almost  wholly 
free  from  deposition  of  tartar;  and  here,  no  doubt,  the  cause  is 
absorption  of  the  alveolar  process  without  any  exposure. 

The  treatment  of  this  disease  is  very  uncertain    and  some- 


SALIVARY    CALCULUS.  355 

what  severe;  indeed,  it  is  only  during  the  last  few  years  that 
any  real  treatment  has  been  attempted.  Riggs,  to  whom  we 
owe  the  introduction  of  the  <^)nly  known  methods  at  all  likely  to 
be  of  service,  and  who,  by  calling  our  attention  so  prominently 
to  the  affection,  has  led  many  to  associate  his  natne  with  it, 
recommends  in  the  iirst  place  a  most  careful  removal  of  all 
salivary  deposition  from  the  exposed  fangs  of  the  teeth.  This 
can  only  be  effected  by  very  narrow  sharp  scalers,  and,  as  it 
causes  both  pain  and  bleeding,  will  generally  necessitate  many 
sittings.  Considerable  mitigation  is,  however,  obtained  by  a 
frequent  employment  of  carbolic  acid  conveyed  to  the  space 
between  the  gum  and  the  necks  of  the  teeth,  on  a  pointed  piece 
of  soft  wood.  Together  with  the  removal  of  the  tartar,  must  be 
that  of  the  exposed  edge  of  the  alveoli,  and  this  must  be  done 
until  it  is  concluded  that  all  diseased  portions  are  removed.  To 
insure  the  removal  of  both,  it  is  advisable,  after  the  scraping 
process,  to  apply  to  the  parts  a  strong  or  diluted  solution  of 
aromatic  sulphuric  acid.  Not  having  been  able  to  procure  the 
original  account  of  Riggs's  treatment,  we  may  perhaps  not  have 
done  him  full  justice;  but  we  believe  that  the  statement  given 
above  accords  in  the  main  with  what  he  has  recommended. 
After  the  operation  has  been  performed,  the  patient  must  be 
instructed  to  pay  particular  attention  to  tlie  gums,  brushing 
them  frequently  with  a  soft  brush,  and  counteracting  any  tend- 
ency to  congestion  by  the  application  of  tinct.  iodinii  comp., 
tannin,  or  alum  or  borax  solution.  We  can  hardly  venture  to 
hope  that  teeth  so  treated  will  ever  at  the  parts  scraped  become 
united  to  the  surrounding  mucous  membrane,  but  this,  if 
healthy,  may  come  into  such  close  contact  with  them  as  to  pre- 
vent the  access  of  fluids  and  the  consequent  deposition  of  tartar. 
"With  regard  to  tartar  or  salivary  calculus,  which  is  deposited 
upon  the  teeth  in  much  the  same  manner  as  are  the  lime-salts 
upon  the  sides  of  a  steam-boiler,  we  may  saj^  a  few  words.  Ana- 
lyses have  shown  it  to  be  chiefly  composed  of  earthy  phosphates 
and  animal   matter.'     It  is  the  latter  doubtless  that  gives  to 

'  Analysis  of  tartar  (Berzelius). 

Earthy  phosphates 79.0 

Mucus 12.5 

Ptyaline 1.0 

Animal  matter  sol.  in  hydrochloric  acid  .         .         .  7.5 

100.0 


356    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

most  varieties  its  repulsive  odor.  The  organic  matter  is  of 
course  furnished  by  the  mucus  and  epithelia,  also  b}'  the  lepto- 
thrix  and  micrococci  found  in  abundance  in  many  mouths,  and 
doubtless  occasionally  by  minute  portions  of  food  :  the  lime- 
salts  from  the  saliva  in  which  they  are  held  in  solution. 
Some  observers  have  described  the  existence  of  minute  Crustacea 
in  salivary  calculus  ;  but  this  is  probably  an  error  arising  from 
the  appearance  presented  by  the  precipitation  of  lime-salts  in  a 
colloid  fluid. 

Tartar  varies  in  character,  owing,  no  doubt,  to  the  conditions 
under  which  it  is  deposited;  thus,  where  very  rapid  and  in 
large  quantities,  it  is  of  a  whitish-yellow  color,  and  compara- 
tively soft.  It  issuriirising  to  what  an  extent  it  can  accumulate 
in  a  little  time:  we  have  under  observation  a  young  lady  who 
has  for  some  j'ears  visited  us  annually,  and  on  every  occasion 
we  have  removed  quite  as  much  tartar  as  represents  in  bulk 
the  crowns  of  the  teeth  on  which  it  has  collected.  Most  of  her 
teeth  have  become  very  loose,  but  are,  for  their  condition,  re- 
markably free  from  tenderness,  ami  in  no  respect  resemble  the 
condition  to  which  Riggs  has  called  our  attention.  There  is  in 
her  ease  almost  as  much  deposit  on  the  upper  as  on  the  lower 
teeth,  which  is  unusual,  especially  with  this  variety;  the  part 
where  it  is  most  commonly  met  with  being  the  depression  formed 
by  the  inner  surface  of  the  body  of  the  lower  jaw  in  front,  and 
the  root  of  the  tongue  behind:  it  is  here  that  the  saliva  collects 
in  largest  quantity,  and  by  evaporation,  and  probably  chemical 
changes,  doubtless  increased  alkalinity,  the  lime-salts  are  pre- 
cipitated, carrying  down  with  them  more  or  less  of  the  insoluble 
and  semi-soluble  organic  matter.  A  second  variety  is  much 
harder  in  consistency  than  that  last  mentioned,  and  of  almost  a 
black  color;  it  is  usually  deposited  in  patches,  or  in  the  form 
of  a  ring  around  the  teeth  at  their  necks,  and  often  just  below 
the  free  margin  of  the  gum  ;  and  it  ajipears  quite  as  common  to 
the  upper  as  to  the  lower  teeth,  to  which  it  adheres  with  con- 
siderable tenacity.  The  third  variety  may  be  that  which  we 
have  already  described  as  in  connection  with  Riggs's  disease,  so 
called.  A  fourth  variety  is  that  which  appears  most  frequently 
upon  the  upper  front  teeth  of  young  persons  just  above  the 
margin  of  the  gum,  and  is  of  a  greenish-black  color;  it  is  very 
thinly  deposited,  and  so  difficult  to  remove,  that  some  have 


SALIVARY    CALCULUS.  357 

reo;arded  it  rather  as  a  changed  condition  of  the  cemental  cover- 
ing to  tlie  enamel  (iS'asni3'th's  membrane)  than  as  any  deposition. 
It  certainly,  when  removed,  leaves  the  enamel  roughened  atid 
minutely  pitted  ;  it  is  said  never  to  return  after  removal,  but  of 
this  we  speak  doubtfully. 

[This  has  been  claimed  to  be  a  vegetable  growth  that  throws 
down  attachments  which  themselves  partly  disintegrate  the  tooth 
substance,  and  are  supi,>osed  to  assist  in  the  destruction  both  by 
this  direct  action  and  by  ftivoring  the  retention,  and  thereby 
the  decomposition  of  food,  upon  certain  territories  of  the  tooth 
surface.] 

Teeth  coated  with  tartar  appear  less  liable  to  caries  than  teeth 
upon  which  itnevercollects,  and  we  invariably  find  that,  when  the 
front  teeth  of  the  lower  jaw  have  a  great  tendency  to  decay,  tartar 
is  absent  from  them.  [i!^oticeable  exceptions  have  been  met  in 
the  writer's  practice,  markedly  one  of  a  mother  and  daughter 
where  the  accumulated  deposit  was  not  of  the  ordinarj'  yellowish 
chalky  nature,  which  the  author  prol)ably  means,  but  rather  of 
the  brownish  and  hard  character  which  is  most  frequently  met 
with  in  mouths  where  little  or  no  decay  can  be  found.]  If  then 
it  were  not  for  the  indirect  injury  that  tartar  occasions,  as  also 
for  the  discomfort  and  unpleasantness  that  its  [)resence  creates, 
we  might  consider  its  removal  more  than  superfluous,  especially 
as  we  occasionally  meet  with  a  carious  cavity  in  which  its  depo- 
sition has  made  a  fair  filling.  A  small  amount  of  yellow  or 
brownish  tartar  at  the  backs  of  the  lower  front  teeth  is  more  a 
matter  of  general  existence  than  not,  and  appears  productive  of 
little  harm.  Ver}'  different  is  the  presence  of  an  equal  quantity 
on  the  anterior  as[>ect  of  a  lower  incisor,  at  the  margin  of  the 
gum,  which,  by  continual  increase  in  the  direction  of  the  tang, 
causes  its  anterior  surface  to  become  exposed,  occasionally  almost 
up  to  its  apex.  When,  therefore,  we  meet  with  it  in  such  posi- 
tions, and  indeed  in  all,  except  perhaps  the  very  slight  deposits 
at  the  backs  of  the  lower  front  teeth,  it  certainly  ought  to  be 
removed  ;  and  this  is  best  accomplislied  by  pressing  upon  it 
chiefly  in  the  direction  of  the  fangs  of  the  teeth  with  suitable 
sharp-pointed  steel  instruments.  The  form  which  we  have 
found  most  useful  is  that  figured  below  (Fig.  305)  ;  but  it  is  not 
to  be  employed  in  the  manner  that  we  have  experienced  upon 
ourselves,  viz.,  hooked  under  the  lower  edge  of  the  deposit  and 


358 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


then  pulled  upwards,  which  lacerates  the  gum,  jars  the  teeth 
considerably,  and  raost  imperfectly  removes  the  mass.  [Here, 
although  not  a  very  important  matter,  the  writer  would  de- 
cidedly prefer  the  method  condemned,  as  more  expeditious,  less 

Fig.  305. 


A  form  of  scaler  whicli  is  verv  serviceable  in  removing  tartar. 

likely  to  cause  pain  or  injury  to  the  tooth,  and  not  calculated  to 
push  the  detached  particles  of  calculus  under  the  gum  and 
thereb}'  cause  irritation.]  The  thumb  of  the  hand  holding  the 
instrument  should  rest  upon  the  cutting  edge  or  masticating 
surface  of  the  tooth  operated  on,  in  order  to  steady  it,  and  then, 
hy  the  point  of  the  instrument  being  pressed  into  the  tartar  and 
in  the  direction  of  the  root,  or  perhaps  somewhat  towards  either 
side  of  it,  the  mass  flakes  oft"  in  fragments  of  considerable  size. 
In  the  j»rocess  of  scaling,  great  care  should  be  exercised  to  re- 
move all  fragmentary  portions  from  between  the  teeth,  where 
they  not  unfrequently  extend  to  some  distance  below  the  sur- 
face and  are  often  overlooked.  After  removal  of  all  visible  por- 
tions of  the  concretion,  for  which  a  variety  of  shapes  in  the 
scalers  may  be  necessary,  the  more  minute  remnants  may  be 
removed  by  brushing  with  moistened  pumice-powder,  a{»plied 
on  cane-roots,  or  by  the  little  circular  brushes  (Fig.  305)  which 
are  rotated  by  the  burr-engine  and  are  so  serviceable  for  the 
general  cleansing  of  the  teeth.  [A  piece  of  cotton- wool  or 
string  or  lamp  wick,  wound  u^-on  an  old  or  broken  engine  point, 


SALIVARY    CALCULUS.  359 

will  make  an  excellent  porte  polisher  for  this  purpose  and  for 
finishing  fillings  or  filed  surfaces.  It  is  quickly  made,  and  there 
is  no  temptation  to  use  it  for  a  second  patient.]  All  tartar  hav- 
ing beei)  removed,  and  the  surfaces  of  the  teeth  left  smooth  and 

Fi?.  306. 


Two  forms  of  brush  to  be  used  -with  the  dental  engine  for  polishing  the  teeth  after  the 
removal  of  tartar. 

comfortahle,  the  patient  will  find  much  benefit  from  an  astrino-. 
ent  lotion,^  both  to  allay  irritation  caused  to  the  gum  by  the 
process,  and  also  to  render  the  now  more  exposed  necks  of  the 
teeth  less  sensitive  to  changes  of  temperature.  A  careful  and 
frequent  use  of  the  tooth-brush  must  be  insisted  on,  a  soft  one  in 
preference  to  a  very  hard  one,  at  least  for  a  time ;  and  a  dentifrice 
composed  of  prepared  chalk  and  pure  soap,  flavored  with  a  little 
orris-root,  and  scented  with  a  minute  quantity  of  oil  of  roses, 
may  be  employed  with  much  advantage,  and  to  this  can  be 
added,  if  necess.iry,  a  small  quantity  of  tannin,  borax,  or  alum. 

[The  latter  has,  however,  been  much  objected  to,  as  liable  to 
injure  the  enamel,  and,  since  the  desired  astringeney  can  be 
better  and  more  pleasantly  supplied  by  pulverized  galls  or  gallic 
acid,  it  will  be  safer  to  discard  it.] 

By  removal  of  the  tartar  we  shall  have  got  rid  of  a  very  com- 
mon local  cause  of  congestion  of  the  gum,  to  which  subject  we 
now  return.  With  regard  to  treatment,  we  may  in  the  milder 
cases  recommend  some  simple  astringent  lotion,  of  which  we 
have  found  the  tincture  of  tannin  already  mentioned  to  be  the 
most  serviceable;  in  the  more  severe  cases,  and  those  which  are 
more  of  the  character  of  chronic  inflammation,  we  shall  have  to 

'  R.  Acidi  tannic!,  5«s. 

(Eau  de  Cologne)  jiv. 
M.  ft.  applicatio. 
About  10  or  12  drops  of  the  above  to  a  teaspoonful  of  tepid  water,  lo  be  held  in 
the  mouth  two  or  three  times  daily. 


360    MANUAL  OP  DENTAL  SURGERY  AND  PATHOLOGY. 

pa}^  greater  attention  to  the  general  health.  In  persons  thus 
suttering  we  shall  generally  find  the  whole  alimentary  mucous 
tract  to  be  affected,  and  remedies  acting  directly  on  that  mem- 
brane will  be  indicated;  thus  ipecacuaidia  in  one  to  two  grain 
doses  often  does  much  to  relieve,  but  that  which  we  have  found 
most  successful  has  been  nnx  vomica,^  but  it  is  a  remedy  that 
must  be  carefully  watched.  In  cases  of  more  acute  inflamma- 
tion of  the  gums,  there  is  generally  pain,  and  of  a  burning  char- 
acter; and,  as  it  is  rare  for  it  to  exist  without  some  abrasion  of 
the  delicate  epithelial  surface,  we  get  ulceration,  under  which 
head  we  may  best  consider  the  subject. 

Ulcerations  of  the  Gum. — Aphthous  ulcerations  of  the  mu- 
cous membrane  covering  the  gums  are  by  no  means  uncommon, 
especially  in  those  who  have  long  suffered  from  prostrating  ill- 
ness, and  are  frequently  witnessed  towards  the  termination  of 
phthisical  disease.  Less  common,  but  yet  often  met  with  in  the 
comparatively  healthy,  they  appear  in  connection  with  d^^speptic 
conditions,  and  usually  present  themselves,  in  the  first  place,  as 
small  detached  vesicles,  not  unlike  those  in  herpes,  which  soon 
burst,  leaving  a  denuded  surface.  On  the  tongue,  such  ulcers, 
for  they  are  most  probably  the  same,  although  we  cannot  so 
often  here  witness  their  vesical  stage,  are  very  sensitive,  giving 
a  sharp  pricking  or  stinging  sensation  when  touched,  and  ap- 
pearing  like  a  small  circle  of  lighter  color  than  the  surrounding 
tissues,  with  a  central  dark  spot  as  if  drawn  by  a  pair  of  com- 
passes. 

With  the  thrush  of  children  some  have  associated  ordinary 
aphthous  ulceration,  but  the  former  has  certainly  a  dift'erent 
origin  and  character.  It  is  due  to  the  presence  of  a  cryptogamic 
growth,  the  o'idium  albicans,  which  finds  suitable  conditions  for 
growth  and  development  in  the  mucous  membrane  of  children 
fed  under  unfavorable  conditions.  [This  form  of  vegetuble 
parasite  is  often  the  cause  of  considerable  suft'ering  in  older 
persons.  The  writer  calls  to  mind  the  case  of  a  patient  who 
had  been  for  years  under  the  care  of  numbers  of  practitioners, 

'  ^.  Extr.  nucis  vom.  gr.  vj.  or  I^.  Tinct.  iiucis  voin.  v\kv. 

Mist,  acacise,  Ex  aqua 

Tinct.  cardam.  co.,  aa  f^j.  bis  tcrve  die. 

Aquijc  dest.  ad  f§vj. 
One-sixth  part  for  a  dose. 


ULCERATIONS    OF    THE    GUM.  361 

both  general  and  special,  who  she  said  had  in  vain  attempted  to 
cure  her.  Patches  of  the  size  of  25  to  50  cent  silver  pieces  were 
on  the  tongue,  cheeks,  and  soft  palate.  The  growth  was  imme- 
diately checked  by  the  application  of  the  tincture  of  iodine, 
followed  by  an  astringent  and  stimulating  mouth-wash  fre- 
quently used.  A  reapplication  of  the  iodine  was  made  every 
few  days  if  the  oidium  albicans  made  its  appearance,  and  in 
less  than  two  weeks'  time  the  mouth  was  perfectly  healthy. 
The  trouble,  however,  recurs  at  times,  generally  in  the  spring 
season,  but  always  yields  to  the  above  treatment.]  Thrush  ap- 
pears at  first  in  small  patches,  of  white  iiocculent  matter,  not 
unfrequentl}^  mistaken  for  small  portions  of  milk-curd;  but  its 
true  nature  is  seen  when  wiped  otf,  as  it  then  leaves  a  surface 
devoid  of  epithelium,  studded  with  minute  bloody  spots. 

In  the  treatment  of  ordinary  aphthous  ulceration  we  may 
with  advautage  apply  locally  mel-boracis  on  a  camel-hair  brush. 
If  it  occur  in  the  moderately  healthy,  a  course  of  alterative 
treatment,  combined  with  mild  purgation,  may  be  desirable. 
When  it  aifects  the  subjects  of  exiiausting  diseases,  the  local 
treatment  above  suggested  is  alone  applicable.  The  painful 
ulcers  of  the  tongue  may  generally  be  cured  by  touching  them 
with  a  crj'stal  of  sulphate  of  cop[)er,  or  with  a  mixture  of  strong 
carbolic  acid  and  glycerine. 

In  the  thrush  of  infants,  attention  must  be  directed  first  to 
the  diet,  which  is  most  frequently  at  fault.  In  the  next  place, 
the  mouth  should  be  carefully  wiped  out  after  each  meal  with 
a  soft  piece  of  rag  dipped  in  cold  water,  the  rag  not  being  used 
a  second  time;  the  denuded  surfaces  should' be  dabbed  with  a 
small  piece  of  rag  attached  securely  to  a  piece  of  wood,  and 
moistened  with  a  solution  of  alum  or  borax,  about  eight  grains 
to  the  ounce  of  water;  in  intractable  cases,  a  dilute  solution  of 
carbolic  acid  and  glycerine  may  be  used.  The  appearance  of 
thrush  about  the  anus  will  indicate  a  more  general  extension  of 
the  disease  in  the  alimentary  mucous  track,  and  indicate  a  more 
serious  condition. 

Another  variety  of  ulceration  has  received  the  somewhat  in- 
definite appellation  of  ulcerative  stomatitis:  it  is  chiefly  met 
with  in  children  residing  in  the  unhealthy  districts  of  large 
cities,  but  we  have  met  with  it  in  cases  where  sanitary  condi- 
tions could  not  be  found  fault  with,  except  that  green  vegetable 


3:32    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

diet  was  almost  wholly  excluded  from  their  bill  of  fare.  The 
latter  cases  were  those  of  children  at  a  large  public  institution, 
who  invariably  suffered  towards  the  end  of  a  term.  The  least 
local  irritation  determined  the  ulceration,  even  regulation  plates 
had  to  be  abandoned  on  this  account ;  yet  on  their  return  from 
vacation  their  mouths  had  resumed  a  perfectly  healthy  aspect. 
The  disease  usually  presents  itself  during  early  childhood,  from 
two  to  five  or  seven  years  of  age  being  the  commonest  [teriod.  It 
is  more  common  in  the  lower  than  in  the  upper  jaw,  and  is 
generally  seen  upon  the  outer  margin  of  the  gum  at  the  necks 
of  the  first  and  second  temporary  molars  or  the  incisors,  and 
most  frequently  but  not  always  confined  to  one  side  of  the  mouth. 
Seen  in  the  earl}'  stages  the  mucous  membrane  at  the  necks  of 
the  teeth  will  be  found  deeply  congested  with  venous  blood, 
swollen,  and,  from  tension,  somewhat  shining,  the  conditions 
being  much  aggravated  by  the  presence  of  necrosed  teeth, 
denuded  fangs,  or  tartar.  As  the  disease  progresses,  ulceration 
of  a  gray  ashy  color  makes  its  appearance  at  the  free  margin  of 
tiie  gum,  and  is  accompanied  by  a  thin  sanious  discharge,  of 
offensive  odor. 

This  condition  of  things  continuing,  more  of  the  mucous 
membrane  becomes  involved,  while  the  opposing  cheek,  where  it 
rests  against  the  gum,  sutlers  in  like  manner.  At  this  stage 
there  is  some  swelling  observable  on  the  outer  surface  of  the 
cheek.  Further  extension  leads  to  exposure  and  exfoliation  of 
the  alveoli,  with  loss  of  the  temporary  teeth,  and  occasionally 
also  of  the  bone  containing  the  ery[)ts  of  the  permanent  ones. 
"Whether  the  disease  if  left  to  itself  would  go  on  until  lite  was 
involved,  or  undergo  a  spontaneous  cure  at  an  advanced  age, 
it  is  difl^icult  to  say:  its  having  a  constitutional  cause  would 
favor  the  former  conclusion;  but,  no  doubt,  even  the  most 
neglected  cases  meet  with  treatment  before  such  results  could 
be  likely  to  happen. 

The  disorder  is  happily  so  thoroughly  under  control,  that, 
were  we  asked  to  mention  a  disease  for  wliich  there  was  a  cer- 
tain specific,  we  should  unhesitatingl}'  pronounce  ulcerative 
stomatitis  to  be  the  disease,  and  chlorate  of  potash  the  specific. 
The  effect  of  the  drug  is  visible  in  a  few  days,  and  all  hut  the 
worst  cases  aftpear  cured  in  ton  days  to  a  fortnight,  and  this 
without  any  local  application  whatever.      The  quantity  of  the 


ULCERATIONS    OF    THE    GUM.  363 

salt  that  WG  employ  is,  in  infants  u\)  to  three  years  old,  three  to 
five  grains;  to  four  or  five  years  old,  ten  grains;  and  to  seven  or 
nine  years  old,  fifteen  strains  ;  in  all  tliree  times  daily,  and  diluted 
in  v^'^ater,  varying  in  quantity  from  a  teaspoonful  to  an  ounce, 
to  which  a  little  sugar  may  be  added  if  desired.  In  the  very 
debilitated,  quinine  may  be  combined  with  advantage,  and  fresh 
vegetable  diet  should  certainly  be  recommended. 

[But  in  all  these  diseases,  as  well  as  in  health,  too  much 
stress  cannot  be  laid  upon  the  importance  of  pure  air. 

The  writer's  consideration  of  the  value  of  wood  smoke  as  a 
disinfectant  for  the  teeth,  was  suggested  by  some  experiments 
with  it  in  cases  of  scarlet  fever.  Believing  that  the  nascent 
creasote  would  prove  an  active  and  more  [)enetrating  antiseptic 
than  any  ordinarily  used,  and  further  reasoning  upon  the  advisa- 
bility of  some  ready  and  convenient  means  of  destroying  the 
septic  effluvia,  and  preventing  the  retention  of  the  specific  poi- 
8  >n  in  the  apartments,  he  had  the  sick-room  warmed  by  a  stove 
burning  wood,  and  at  regular  intervals  had  the  damper  turned 
so  as  to  drive  the  smoke  into  the  room.  It  need  only  be  added 
that  blankets,  bureau-drawers,  the  seams  of  the  floor  and  every 
part  of  the  bedding,  the  body  and  even  the  hair  of  the  patients 
were  kept  constantly  saturated  with  the  odor.  The  disease  not 
only  did  not  spread,  but  was  ap[)arently  mitigated  very  mark- 
edly. The  writer  is  persuaded  that  measles,  scarlet  fever,  diph- 
theria, and  many  of  the  diseases  which  of  late  years  seem  to  have 
grown  to  be  of  a  more  virulent  type,  are  very  much  indebted 
for  this  deadly  power  to  the  modern  system  of  heating  with 
hot-air  and  its  mixture  with  coal  gas.] 

Besides  the  loss  of  some  of  the  permanent  teeth,  troublesome 
cicatrices,  binding  the  cheek  to  the  gums,  may  result;  but, 
unless  they  interfere  to  any  extent  with  the  opening  of  the 
mouth,  they  will  not  be  of  much  consequence.  The  above-men- 
tioned conditions  a[>pear  in  the  most  severe  form  when  follow- 
ing the  exanthemata,  es[)ecially  scarlatina,  measles,  and  small- 
pox, and  less  frequently  after  continued  fever;  it  is  a  question 
whether  they  are  not  then  identical  with  the  cases  to  which 
fealter  was  the  first  to  draw  attention,  and  for  which  he  offers 
an  ingenious  explanation.  lie  points  out  that  the  extensive 
necrosis  of  the  maxillary  bones,  occurring  after  the  above-men- 
tioned diseases,  and  in  the  order  of  frequency  in  wiiich  we 


364 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


Fiff.  307. 


have  placed  them,  occurs  usually  at  an  age  when  the  most  act- 
ive tooth-development  and  rapid  nutritional  changes  are  going  on 
in  the  jaws,  viz.,  between  three  and  eight  years,  five  years  being 
the  most  common  age.  He  believes  that,  as  in  the  case  of 
maxillary  necrosis  due  to  phosphorus  fumes,  so  in  that  following 
the  eruptive  fevers,  the  cause  is  the  application  of  a  specific 
poison  to  the  vascular  parts  of  the  teeth ;  but  that  in  the  latter 
the  poison  is  generated  within  the  individual.  As  the  poison 
of  the  exanthemata, — scarlatina  in  particular, — aftects  especially 
the  dermal  tissues,  the  teeth,  as  a  part  of  the  dermal  system, 
sufi:er  with  the  rest,  and  in  like  manner  affect  their  surround- 
ings. The  exfoliation  here  figured  (Fig.  307)  was  the  result  of 
a  neoi;lected  case  of  undoubted  ulcerative  stomatitis  occurring* 
within  a  lew  weeks  after  measles.  It  yielded 
readily  to  chlorate  of  potash  ;  that  is,  the  ul- 
cerative condition  entirely  disappeared ;  but 
the  necrosis  which  comprises  the  greater  por- 
tion of  the  right  superior  maxilla  did  not  be- 
come evident  until  some  two  months  afterwards. 
Salter,  however,  says,^  "it  has  seldom  been 
Necrosis  of  nearly     pi-eccded  bv  Swelling  or  r)ain,  or  accompanied 

the    whole    of    the       ^  _  '^  &  1  '  i 

right  superior  max-     by  periosteal  absccss,"  and,  moreover,  "  its  ten- 
iiia  of  a  child  the     (jg^jcyis  to  be  symmetrical."     The  above-men- 

result  of  ulcerative  «/  -^ 

stomatitis,  occur-  tioucd  casc  is  tlicu  probably  one  of  ordinary 
riQgsoona  er  mea-  ^^i^^gj-r^^jye  stomatitis  intensified  by  the  ett'ects 
of  measles.  With  ulcerative  stomatitis  lias 
often  been  confounded  another  form  of  ulceration,  happily  rare 
in  its  occurrence,  because  of  a  much  more  serious  character,  very 
often  fatal  in  its  results. 

[The  respiratory  track  is  much  soothed  by  the  smoke  from 
bituminous  coal  or  by  the  odor  of  tar,  and  the  writer  doubts  not 
that  these  ulcerated  surfaces  would  be  less  likely  to  occur  if  occa- 
sionall}''  a  piece  of  the  former,  the  size  of  a  walnut,  were  burned 
in  tlie  apartment,  or  if  some  oakum  or  freshly  tarred  ro[)e,  were 
kept  to  impregnate  the  air  in  the  living  room  or  nursery.  He 
has  frequently  cut  short  threatened  attacks  of  croup  by  the 
Bmoke  of  the  former,  and  to-day  one  of  the  most  successful  means 


»  Dental  Pathology  and  Surgery,  by  S.  James  A.  Salter,  M.B.,  F.R.S.,  p. 
810. 


ULCERATIONS    OF    THE    GUM.  365 

of  relieving  the  consumptive's  painful  cough  is  by  exposing  large 
surfaces  coated  with  tar  for  the  air  of  the  room  to  absorb.] 

Cancrum  oris,  or  gangrenous  stomatitis,  as  it  has  been  vari- 
ously termed,  is  a  disease  most  common  in  children  aged  from 
two  to  tw^elve  years.  It  does  not  always  appear  to  attack  the 
most  emaciated  or  unhealthy,  although  more  frequently  tliose 
residing  with  unhealthy  surroundings,  and  especially  those  who 
have  suffered  from  exhausting  fevers  and  other  diseases.  It 
commonly  appears  upon  the  inner  surface  of  the  cheek,  soon 
causing  it  to  swell,  and  giving  it  on  the  outer  surface  a  promi- 
nence, tense,  red,  and  glistening  like  an  apple.  To  the  touch  it 
ajipears  dense  and  unyielding.  Witii  the  swelling  of  the  cheek 
the  neighboring  glatids  will  be  found  more  or  less  enlarged,  and 
the  salivary  secretion  increased,  being  of  a  thick  ropy  consist- 
ency. As  the  disease  advances,  there  will,  on  inspection  of  the 
mouth,  be  seen — not  without  difficulty,  owing  to  the  tenseness 
of  the  cheek,  unless  the  practitioner  employs  a  small  mouth- 
mirror — a  ragged-edged  brownish  ulcer,  whilst  the  gums  oppo- 
site appear  to  share  the  same  condition.  As  the  disease  pro- 
gresses, the  saliva  becomes  highly  offensive,  tinged  with  blood, 
and  colored  by  the  disintegrated  tissues  separated  from  the  ulcer- 
ated surface.  The  ulceration,  which  extends  from  the  cheek  to 
the  adjacent  mucous  membrane,  soon  involves  the  alveolar  pro- 
cess and  the  body  of  the  bone  itself.  On  the  cheek  the  promi- 
nent red  spot  becomes  black,  and  this  is  soon  followed  by 
sloughing,  which  exposes  the  interior  of  the  mouth  and  reveals 
the  frightful  mischief  which  has  occurred,  and  which  is  gene- 
rally out  of  all  proportion  to  the  apparent  spirits  and  the  pain 
suffered  by  the  patient,  who,  after  this,  soon  sinks  exhausted. 
This  is  but  a  very  imperfect  sketch  of  this  frightful  disease  ;^  it 
is  hardly  likely  to  come  under  the  attention  of  the  dental  sur- 
geon in  his  ordinary  vocation,  yet  it  is  well  that  he  should  be 
able  to  recognize  it,  as  it  is  only  in  the  earliest  stages  that  the 
disease  can  be  grappled^with  successfully. 

The  treatment  will  be  first  and  chiefly  directed  to  the  local 
conditions.  The  patient  being  placed  under  chloroform,  strong 
nitric  acid  should  be  applied  to  the  ulcerated  surface  on  the 

'  For  an  excellent  account  in  the  English  language  of  Gangrenous  Stomati- 
tis, see  West  on  Diseases  of  Infancy  and  Childhood,  p.  652  et  seq. 


366    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

interior  of  the  cheek,  which  may  be  best  accomplished  bj  con- 
veying it  upon  a  piece  of  amadou  held  by  dressing-forceps:  the 
amadou  takes  up  a  considerable  quantity,  and  the  acid  is  less 
likely  to  drop  from  it  than  from  lint  or  cotton.  The  opposing 
surface  of  the  gum  must,  if  possible,  be  protected  by  a  spoon  or 
cheek-retractor,  unless  the  ulceration  has  extended  to  it  also; 
but  the  risk  of  touching  healthy  mucous  membrane  must  not 
override  the  certainty  of  bringing  the  acid  well  into  contact 
with  the  gangrenous  parts.  In  severe  cases  the  thermal  cautery 
might,  we  suggest,  be  advantageously  employed  as  well  as  the 
nitric  acid.  Soothing  applications,  combined  with  unirritating 
antiseptics,  should  follow  the  cauterization,  wdiilst  the  patient 
must  be  w^ell  supported  by  nourishing  diet,  especially  strong 
extract  of  meat,  stimulants,  and  tonics.  Port  wine,  bark,  and 
iron  are  strongly  indicated;  chlorate  of  ];)Otash,  which  in  some 
hands  has  proved  of  great  service,  may  also  be  tried  in  doses  of 
10-20  grains  every  four  hours.  From  time  to  time  the  mouth 
must  be  examined,  and  the  nitric  acid  reapplied  to  any  spot 
showing  extension  of  the  disease.  In  some  cases  much  milder 
treatment  has  proved  successful,  but  for  typical  ones  bold  and 
severe  measures  can  alone  be  relied  on. 

Ulcerations  of  the  gum  may  arise  from  other  causes  and  con- 
ditions than  those  mentioned  ;  thus  in  syphilis,  salivation,  and 
strumous  and  malignant  affections,  tijey  appear  in  connection 
witlj,  sometimes  as  the  forerunners  of,  n.ecrosis  of  the  maxillse. 
Broken  teeth,  or  even  worn-down  teeth,  presenting  sharp  and 
irregular  surfaces,  are  a  very  fi-equent  cause  of  ulceration  of  the 
mucous  membrane  of  the  mouth.  Those  formed  on  the  tonorue 
are  often  considerable  in  size,  intensely  painful,  and  at  times  of 
very  suspicious  appearance;  the  filing  smooth  or  removal  of 
such  teeth  will,  if  the  cause  be  purely  local,  soon  effect  a  cure. 
AVe  cannot,  however,  too  strongly  impress  u[)on  our  patients  the 
importance  of  having  such  sources  of  irritation  removed  as  soon 
as  possible;  for,  should  any  tendency  to  rpalignant  disease  exist, 
they  would  be  most  likely  to  determine  its  ai)pearance. 

We  frequently  find  ulceration  arising  in  the  neigiiborhood  of 
the  outer  and  posterior  as[)ect8  of  a  lower  third  molar  which  is 
carious  at  this  spot,  and  irritates  the  mucous  membrane  moved 
over  it  when  the  mouth  is  opened  or  shut.  Filling,  filing,  or 
extraction  will  remedy  the  evil,  but  at  the  same  time  we  may 


NECROSIS    OF    THE    JAAVS.  367 

employ  with  great  advantage  tlie  combination  of  chlorate  of 
potash  with  decoction  of  popjiies  spoken  of  at  page  31. 

We  have  already  alluded  to  cases  where  the  roots  of  tempo- 
rary teeth  became  denuded  of  gum,  and,  owing  to  the  advance 
of  the  permajient  teeth,  project,  and  often  severely  ulcerate  the 
cheek.  This  occurs,  though  less  commonly,  in  coimection  with 
permanent  teeth,  as  their  fangs  when  exposed  are  not  pressed 
outwards  in  the  same  manner. 

We  have  on  more  than  one  occasion,  whilst  considering  the 
subject  of  ulcerations  of  the  gum,  alluded  to  necrosis  of  the  jaws, 
upon  which  matter  it  is  necessary  to  add  a  few  words.  Besides 
a  death  of  portions  of  the  niaxillre,  tiie  result  of  the  ulcerative 
processes  which  we  have  described,  necrosis  may  occur  in  what 
we  term  an  idiopathic  form,  which  term  is  little  better  than  a 
disguise  for  our  not  being  able  to  trace  it  to  its  true  cause. 
W^hen  it  thus  appears,  it  is  very  desirable  that  the  dental  sur- 
geon should  not  overlook  the  real  trouble  of  his  patient,  who 
will  very  likely  apply  to  him  on  account  of  pain  which  he  refers 
to  certain  teeth.  These  may  be  found  free  from  caries,  but,per- 
liaps,  slightly  loose  and  tender  when  percussed.  The  surround- 
ing gum  will  often  indicate  by  its  puffy  condition,  and  appa- 
rently loose  attachment  to  the  subjacent  bone,  wdiat  has  oc- 
curred ;  and  a  fistulous  opening  in  it,  if  such  exist,  will  of  course 
reveal  the  true  state  of  matters.  [The  student  may  be  re- 
minded that  the  fistulse  from  diseased  bone  have  their  openings 
through  small,  teat-like  projections,  and  altliough  the  same 
general  appearance  may  be  met  when  the  teeth  produce  the  ab- 
scesses, the  protrusion  is  generally  very  much  snialler,  ordinarily 
about  the  size  of  one-half  a  grain  of  rice.]  It  is  not  that  he  will 
do  much  harm  in  removing  teeth  which  most  probably  will  he 
lost  in  the  progress  of  the  disease,  but  that  he  may  get,  as  many 
most  unjustly  have  done,  the  unmerited  credit  of  having  caused 
it.  When  the  mischief  has  been  correctly  diagnosed,  we  shall 
do  well  to  warn  our  patient  to  prepare  for  what  will  be  tedious 
and  most  disgusting  to  him  ;  as,  if  w^e  attempt  to  remove  the 
diseased  bone  before  nature  has  set  the  limit  to  its  boundaries, 
and  separated  it  from  its  healthy  surroundings,  we  shall  jiroba- 
bly  do  more  harm  than  good  ;  at  the  same  time  we  have  found 
that,  by  cutting  away,  without  violence,  exposed  and  project- 
ing portions,  we  have  lessened  the  discharge  and  rendered  the 


368    MANUAL  OF  DENTAL  SURGEP.Y  AND  PATHOLOGY. 

mouth  more  comfortable.  [Prof.  Garretson^  objects  to  the  un- 
necessary meddling  with  or  cutting  of  the  dead  bone.]  Support 
by  good  nourishment,  a  moderate  amount  of  stimulant  and 
tonics,  with,  if  possible,  a  change  of  air,  will  be  the  best  means  of 
assisting  nature  to  do  her  work ;  whilst  frequent  washing,  or,  if 
possible,  syringing  with  Condy's  fluid,  weak  solution  of  carbolic 
jicid,  or  the  lotio  soda?  chlorinatfe,  will  reduce  to  a  minimum  the 
offensiveness  of  the  discharges,  which  too  often  causes  a  suscep- 
tible patient  to  be  constantly  sick,  and  to  loathe  his  food.  [Per- 
manganate of  potassa,  a  few  crystals  of  which  may  be  dissolved 
in  a  sufficient  quantity  of  water,  makes  a  disinfectant  mouth 
wash  of  a  pleasing  color,  and  not  exceedingly  unpleasant  taste.] 
As  soon  as  the  sequestrum  is  found  to  be  detached  from  the 
neighboring  bone  it  should  be  removed,  to  effect  which  it  will 
often  be  found  necessary  to  free  it  more  or  less  by  the  knife  from 
the  surrounding  mucous  membrane.  The  portions  of  the  maxillse 
most  liable  to  necrosis  are  undoubtedly  the  alveolar  portions, 
which  it  is  not  difficult  to  account  for  when  we  consider  their 
immediate  relationship  to  organs  so  prone  to  disease  as  are  the 
teeth.  [Carelessness  in  allowing  arsenic  used  for  destroying  pulps 
to  escape  from  the  cavities  and  get  upon  the  gum  or  the  jaw- 
bone, has  likewise  been  a  cause  of  necrosis.  In  one  case,  in  the 
mouth  of  a  lady  who  had  been  under  the  care  of  a  dentist  of 
note,  the  septum  of  bone  between  two  lower  molars  was  de- 
vitalized ;  after  being  a  source  of  annoyance  for  some  months, 
tiie  patient  came  under  the  writer's  care,  and  was  quickly 
relieved  by  the  removal  of  the  sequestrum.]  When  we  con- 
sider how  much  this  portion  of  the  bone  suflers  during  alveolar 
abscess  and  chronic  periodontitis,  it  is  surprising  that  necrosis 
of  more  or  less  of  it  does  not  follow  as  a  rule  rather  than  an 
exception;  indeed,  we  may  to  some  extent  overlook  this  cause 
of  necrosis.  Whilst  we  are  now  writing,  this  matter  is  under- 
going investigation  by  our  colleague,  I.  Lyons,  who  has  already 
collected  several  cases  of  necrosis  in  which  the  history  points  to 
considerable  pain  and  inflammation  having  existed  long  pre- 
viously in  teeth  which  have  ajiparently  recovered,  but  their 
injurious  eftects  on  the  surrounding  bone  have  become  subse- 
quently evident.     Should  this  be  proved  to  be  other  than  excep- 

'  [Qarretson,  Oral  Surgery,  pp.  712-717-723.] 


NECROSIS    OF    THE    JAWS.  369 

tioiial,  it  may  lead  us  to  adopt  a  somewhat  less  conservative 
treatment  with  regard  to  teeth  which  are  the  subjects  of  severe 
periodontitis.  The  teeth  which  ajtpear  most  frequently  to  cause 
necrosis  in  their  neighborhood  are  the  incisors  of  the  upper  jaw: 
whether  this  be  due  to  any  peculiarity  in  the  structure  or  condi- 
tion of  the  bone  at  such  parts,  or  to  the  circumstance  that  we 
are  more  loath  to  remove  these  than  any  other  teeth,  even  when 
much  diseased,  is  a  question  that  we  will  not  venture  to  decide. 
The  exfoliations  are  often  not  considerable,  involving  only  a 
portion  of  tlie  external  alveolar  plate. 

[It  may  likewise  be  remembered  that  this  portion  of  the  bone 
is  liable  to  injuries  from  blows,  being  less  covered  by  muscular 
tissue,  and  is  moreover  at  the  periphery  of  the  htemal  system, 
and  the  l)lood  may  often  fail  to  circulate  in  these  parts  during 
depression  and  weakness.] 

The  necroses  which  occur  in  connection  with  syphilis,  mer- 
curial salivation,  phosphorus-poison,  etc.,  form  a  portion  of  gene- 
ral surgery  which  the  dental  surgeon  will  have  to  study  from 
works  devoted  to  that  subject:  their  consequences  will  more 
direc'ly  afiect  him  as  he  will  be  called  upon  to  supply  the  vacuities 
which  those  diseases  have  effected. 

As  regards  the  removal  of  teeth  in  cases  where  necrosis  is 
going  on,  much  judgment  must  be  exercised.  If  they  are  un- 
sound, and  evidently  a  cause  of  irritation,  they  should  be  ex- 
tracted ;  but,  if  sound  and  not  apparently  exciting  irritation, 
they  maj'  be  left,  in  the  hope  that  new  bone  may,  after  the 
separation  of  the  old,  be  developed  around  them,  as  has  been 
recorded  in  a  few  rare  instances.  The  new  bone  formed  in  the 
lower  maxilla  especially  has  been  shown  to  have  a  strong  tend- 
ency to  become  atrophied  or  absorbed :  some  have  attributed 
this  to  a  want  of  proper  use  or  exercise,  and  it  has  been  suggested 
— even  attempted,  we  believe — to  effect  this  object  by  supplying 
artificial  dentures  to  rest  and  exert  pressure  upon  it,  but  with 
what  result  we  have  never  learned. 

[The  writer  saw  a  most  rem.arkablecase  of  reproduction  of  the 
bone  of  the  lower  jaw,  in  one  of  Prof  Garretson's  patients,  where 
the  floor  of  the  mouth  seemed  to  have  a  bonv  basis  reachins: 
from  one  side  of  the  inferior  maxilla  to  the  other.^] 

'  ["Garretson's  Oral  Surgery," p.  724.] 
24 


370    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


CHAPTEE,    XIX. 

CICATRICES  CLOSING  THE  JAWS. 

These  may  occur  as  the  result  of  most  of  the  forms  of  ulcera- 
tion which  we  have  considered.  Those  resulting  from  ulceration 
of  the  cheek,  by  irritation  of  the  fang  of  a  temporary  tooth, 
or  a  mild  attack  of  ulcerative  stomatitis,  although  very  common, 
are  seldom  of  sufficient  inconvenience  to  call  for  interference. 
Those  following  severe  cases  of  ulcerative  stomatitis,  or  the 
ulcerations  which  are  the  result  of  mercurial  salivation,  or  fol- 
lowing the  exanthemata  or  gangrenous  stomatitis,  are  much 
more  serious  and  difficult  to  deal  with.  In  these  latter  cases 
there  is  often  not  merely  a  loss  of  mucous  structure,  but  like- 
wise of  muscular  and  bony  tissue.  This  hiatus  becomes  in  the 
first  place  supplied  by  connective  tissue,  but,  as  time  advances, 
it  contracts  and  becomes  condensed,  and  in  some  cases  even 
ossified;^  thus  holding,  on  that  side  of  the  mouth,  the  two  jaws 
in  firm  apposition,  nay,  even  drawing  thenr  unnaturally  together, 
as  seen  in  the  displacement  of  the  bicuspid  and  molar  teeth.  It 
is  a  question  whether  something  might  not  be  done  to  prevent 
these  results  by  treatment  at  an  early  stage,  i.  e.,  after  the  ulcera- 
tion has  terminated  and  the  healing  process  commenced,  and 
the  treatment  which  we  are  about  to  suggest  would,  no  doubt, 
be  more  eft'ectual  \vere  it  generally  applied  earlier.  To  those 
only  who  have  undertaken  the  separation  of  webbed  fingers  or 
toes  is  known  the  difficulty  of  preventing  the  reunion  of  the 
severed  tissues,  and  it  is  much  the  same  with  the  mouth.  The 
mere  dissecting-out  of  the  cicatrices  is  utterly  useless,  the  same 
tissue  appearing  in  its  place  soon  afterwards,  perhaps  less  elastic 
even  than  its  predecessor.  Dentists  are  familiar  with  deep  sulci 
covered  with  healthy  mucous  membrane  that  are  met  with  in 

'  Perhaps  we  should  rallier  saj'  makes  way  for  osseous  tissue  developed  at 
the  spots  where  the  bone  has  been  lost. 


CICATRICES    CLOSING    THE    JAWS.  3T1 

the  months  of  patient  individuals  who  have  worn  gold  plates, 
the  outer  edges  of  which  were  too  deep,  and  formed  ulcers, 
these  liealing  over  when  the  furrows  thus  formed  were  suffi- 
ciently deep.  It  occurred  to  one  of  that  body,  J.  C.  Clendon,  to 
treat, — and  we  believe  with  the  greatest  success  yet  attained, — 
cases  where  thecicartricoshad  been  freely  divided  at  their  attach- 
ments to  the  maxilUe,  b}'  means  of  metallic  plates,  the  edges  of 
which  prevented  reunion  between  the  cheek  and  the  opposing 
maxilla3.  The  proceeding  is  best  accomplished  by  placing  the 
patient  under  chloroform,  freely  dividing  the  attachments  of 
the  cicatrix  from  both  maxillce,  and  then  forcing  open  the  jaws 
and  obtaining  an  impression  of  the  defective  side  with  Stent's 
material,  taking  care  that  some  of  it  passes  between  the  divided 
surfaces.  Plates  are  then  struck  up  adapted  to  the  jaws  of  that 
side,  and  firmly  attached  to  the  teeth,  if  there  be  any;  if  not, 
they  should  be  kept  in  place  by  a  strong  spiral  spring,  the  outer 
side  of  such  plates  passing  well  between  the  divided  surfaces. 
The  plates  should  be  introduced  whilst  the  patient  is  again 
under  an  anesthetic,  when  the  knife  may  be  further  employed, 
if  necessary.  The  plates  must  be  worn  continually  for  weeks 
or  even  months  after  their  insertion,  and,  in  addition  to  this,  it 
may  be  necessary  to  retain  between  them  some  elastic  material. 
In  the  more  severe  and  complicated  cases,  where  irregular 
masses  of  bone  fuse  together  the  two  maxillae,  the  only  measure 
at  all  calculated  to  afford  relief  is  the  operation  of  Esmarch, 
which  consists  in  removing  a  wedge-shaped  section  of  the  lower 
jaw  anterior  to  the  obstruction,  and  obtaining  at  that  point  a 
false  joint.  In  a  most  interesting  communication  made  to  the 
Odontological  Society  by  Claude  Rodgers,'  a  case  was  narrated 
in  which  a  lower  gold  i>late  bearing  artificial  teeth,  and  con- 
nected with  an  upper  one  by  springs,  had  completely  divided 
the  jaw-bone  on  the  right  side,  and  had  partiall}'  done  so  on  the 
left  side.  "The  patient  said  he  suffered  little  or  no  pain." 
Surely,  we  are  here  offered  a  valuable  suggestion  for  a  perfect 
and  efficient  means  of  effecting  the  division  of  the  jaw,  with 
the  certainty  of  preserving  its  mobility  ;  indeed,  the  hint  might 
prove  valuable  in  many  other  surgical  cases. 

•  Trans.  Odont.  Soc,  vol.  xii.  p.  53. 


372        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 


CHAPTER    XX.. 

TUMORS  OF  THE  GUM  AND  UPON  THE  JAWS. 

These  can  be  most  conveniently  described  in  relation  to  the 
ptrnctures  which  form  their  essential  part.  Small  mucous  tu- 
mors of  the  gum  are  very  common  ;  the  cause  of  their  origin  is, 
usuallj^,  the  uneven  edge  of  a  carious  tooth.  The  teeth  move 
slightly  in  their  sockets  during  mastication,  as  witnessed  by 
the  polished  facets  wliich  they  present  where  they  touch  each 
other  laterally.  This  movement,  under  the  above-mentioned  con- 
ditions, no  doubt  greatly  irritates  the  gum,  producing  a  hyper- 
trophy of  the  mucous  membrane  at  the  spot,  and  the  growth, 
especially  if  there  be  an  adjoining  tooth,  assumes  a  polypoid 
form.  These  mucous  polyi  are  of  a  darker  color  tlian  the  sur- 
rounding gum,  and  soft,  but  not  very  sensitive  to  the  touch, 
and  they  bleed  very  readily  when  irritated  ;  they  seldom  grow 
as  far  as,  and  hardly  ever  beyond,  the  level  of  the  crow^ns  of  the 
adjacent  teeth.  When  thej^  occur  in  parts  of  the  gum  not 
occupied  by  teeth  their  origin  is  still,  doubtless,  due  to  some 
irritation.  Their  treatment  will  consist  in  removal  :  this  will 
be  readily  effected  by  cutting  them  off  close  to,  or  a  little 
below,  the  level  of  the  gum  with  a  scythe-shaped  lancet  (see 
Fig.  214),  and  touching  with  caustic  the  spots  from  which  they 
liave  sprung.  Those  which  have  their  origin  in  the  irritation 
of  the  ragged  edge  of  a  carious  tooth  will,  if  that  be  not  re- 
moved, soon  appear  again  ;  hence,  after  their  excision,  the  cari- 
ous cavity  must  be  filled.  In  such  cases  the  wooden  wedge 
placed  between  the  teeth  will  be  of  much  service,  as  it  will  not 
only  press  away  the  gum  and  arrest  its  bleeding,  but  also  ena- 
ble the  operator  to  have  the  stopping  perfectly  srnootli  at  the 
cervical  edge  of  the  cavity.  When  these  growths  occur  in  con- 
nection with  roots,  the  latter,  as  a  rule,  should  be  removed, and 
the  poly[)i  will  soon  disappear  of  themselves. 


TUMORS    OF    THE    GUM,    ETC.  373 

Papillary  Tumor  of  the  Gum. — This  growth,  which  was,  we 
believe,  first  described  by  Salter,^  and  which  consists  almost 
entirely  of  hypertrophied  epithelial  tissue,  is  a  rare  form  of 
tumor  which  occasionally  invades  the  region  of  the  jaws.  We 
have  met  with  but  one  instance  of  it,  about  the  size  of  a  bean, 
and  situated  at  the  junction  of  the  alveolar  process  of  the  supe- 
rior maxilla  with  the  body  of  that  bone,  and  resembling  a 
bunch  of  spring  onions  in  miniature.  It  had  existed  several 
years,  and,  as  its  presence  was  not  the  object  of  our  patient's 
visit  to  us,  we  neither  suggested  interfering  with  it  nor  were 
desired  to  do  so,  but  we  inculcated  the  importance  of  carefully 
watching  it,  and  of  having  attention  paid  to  it,  should  it  appear 
to  increase  in  size,  as,  in  a  second  case,  occurring  in  Salter's 
practice,  which  was  operated  on  by  Cock,  of  Guy's,  it  recurred 
and  proved  fatal. 

Vascular  Tumors  of  the  Gum. — In  this  form  of  growth,  it  is 
the  vascular  element  that  chiefly  predominates.  They  do  not 
in  general  extend  to  any  great  distance  above  the  level  of  the 
surrounding  gum,  but  may  occupy  no  inconsiderable  area  upon 
it.  Their  color  is  of  a  deep  purple,  and  their  origin  is  congeni- 
tal, in  fact,  they  are  doubtless  venous  nsevi  upon  the  gums.  In 
their  removal, — the  only  treatment  that  presents  itself, — care 
must  be  taken  to  thoroughly  extirpate  them,  as,  if  any  portion 
be  left,  they  are  almost  certain  to  recur.  In  order  to  do  this 
effectually,  we  recommend  the  operator,  before  employing  the 
knife,  to  mark  around  the  growth  with  nitrate  of  silver  or 
strong  carbolic  acid,  so  that  its  limits  may  be  seen  during  the 
process  of  removal ;  for,  on  its  being  cut  into,  it  almost  entirely 
disappears  through  the  emptying  of  the  vessels  which  give  it 
distinctness.  The  process  will  be  as  much  one  of  scraping  as  of 
cutting,  and  upon  tlie  surface  of  the  bone,  which,  when  laid 
bare,  should  be  washed  over  with  strong  nitric  acid,  or,  better 
still,  be  rubbed  over  with  the  extremity  of  a  thermal  cautery, 
which  will  destroy  such  portions  of  the  growth  as  have  their 
origin  in  the  vessels  of  the  periosteum.  Tumors  having  their 
origin  in  the  periosteum  of  the  jaw,  or  the  alveolo-dental  mem- 
brane, are  by  no  means  unfrequent.     They  may  be  general  or 

'  Guy's  Hospital  Reports  (1866). 


374        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

circumscribed  ;  in  the  former  they  constitute  what  has  been 
termed  hypertrophy  of  the  gums. 

Hypertrophy  of  the  Gums. — This  may  be  congenital,  or 
appear  long  after  birth.  It  seldom  attracts  much  attention 
until  after  the  first  teeth  are  erupted,  when  the  growth  becomes 
more  active.  On  examining  such  a  case,  we  shall  find  the  gums 
greatly  enlarged,  and  nodulated  like  the  surface  of  a  mulberry; 
in  color  a  little  darker  than  normal,  but  still  not  unhealthy- 
looking  in  this  respect.  The  teeth  erupted  appear  moved  by 
the  growth  to  abnormal  positions,  and  are  enveloped  by  it  up 
to,  and  at  times  beyond,  the  summits  of  their  crowns.  In  the 
upper  jaw  the  projections  from  the  alveolar  borders  may  meet 
and  completely  fill  up  the  arch  of  the  palate,  as  in  a  case  which 
we  met  with  at  the  London  Dental  Hospital,  and  which  we 
referred  to  the  consulting  surgeon,  C.  Heath,  who  has  published 
an  account  of  the  same.^  The  non-congenital  cases,  which  never, 
or  hardly  ever,  appear  to  increase  to  the  dimensions  assumed  by 
the  congenital  ones,  seem  to  have  their  origin  in  the  irritation 
caused  by  teeth  ;  for,  when  these,  which  have  been  generally 
loose  for  some  time,  are  removed,  the  hypertrophy,  as  a  rule, 
disappears  (Fig.  308).     It  may,  however,  be,  that  in  removal  of 

Fiff.  308. 


Hypertrophy  of  the  gnm— not  congenital — ivhich  disappeared  after  the  removal 
of  some  loose  teeth. 

the  teeth,  the  alveolar  processes,  from  which  they  appear  chiefly 
to  spring, — as  shown  by  C.  S.  Tomes  in  an  examination  of  the 
case  just  referred  to, — become  absorbed,  and  thus  the  growth 
becomes  atrophied.  Complete  removal  is  the  treatment  indi- 
cated in  the  congenital  cases.     It  is  an  operation   by  no  means 

'  Trails.  Odont.  Soc,  vol.  xi.  p.  18. 


TUMORS    OF    THE    GUM,   ETC.  875 

easy  to  perform,  especially  in  the  case  of  young  children,  and 
must  be  done  piecemeal.  The  knife  must  be  employed  as  much 
as  possible  for  incising  at  the  margins  of  the  growth,  but  the 
bulk  of  the  process  will  have  to  be  performed  with  bone-cutting 
forceps,  which  should  include  a  considerable  portion  of  the 
alveolar  margins  as  well  as  the  growth.  In  arresting  the  haem- 
orrhage and  destroying  small  portions  of  the  growth  not  in- 
cluded by  the  cutting-forceps,  we  shall  find  the  thermal  cautery 
of  much  service.  [The  burr  upon  the  dental  engine  has  been 
much  used  by  Prof.  Garretson,  who  likewise  urges  the  import- 
ance of  leaving  a  goodly  portion  of  the  body  or  lower  rim  of  the 
bone,  even  if  it  may  be  at  the  risk  of  having  to  repeat  the  ope- 
ration, rather  than  cutting  entirely  through  and  destroying  the 
continuity  of  the  bone.^]  In  the  non-congenital  cases,  removal  of 
the  teeth  is  the  treatment ;  for,  if  an  attempt  were  made  to 
remove  the  growth  and  save  the  teeth,  portions  would  be  almost 
sure  to  be  left  to  incite  further  growth  ;  still,  if  the  teeth  ap- 
pear sound,  firm,  and  useful,  such  an  attempt  may  be  made. 

Epulis. — The  more  circumscribed  tumors,  the  chief  constitu- 
ents of  which  are  fibrous  tissue,  and  which  usually  come  under 
the  denomination  of  fibrous  epulis,  ap[)ear  closely  connected 
with  those  last  mentioned,  as  regards  both  their  structure  and 
their  seat  of  origin.  Their  being  so  frequently'  found  in  con- 
nection with  diseased  teeth,  or  roots  of  teeth,  would  lead  us  to 
conclude  that  they  resulted  from  irritation  of  the  periosteum  of 
the  jaw,  or  alveoli  of  the  teeth  ;  they  occasionally  arise,  how- 
ever, in  the  proximity  of  perfectly  sound  ones.  In  color  their 
surfaces  resemble  that  of  healthy  mucous  membrane,  except 
where  they  are  from  their  size  bitten  upon  by  opposing  teeth, 
or  otherwise  irritated,  when  they  appear  indented  and  super- 
ficially ulcerated.  Upon  pressure  they  feel  either  smooth  or 
nodulated,  firm,  and  slightly  elastic  ;  moderate  pressure  is  not 
attended  with  pain ;  and  it  is  probable,  from  their  altogether 
painless  nature,  that  prior  to  the  days  of  anaesthetics,  patients 
allowed  them  to  grow  to  enormous  dimensions  before  resorting 
to  medical  advice;  now  they  seek  sooner  to  be  relieved  of  their 
inconveniences,  and  we  seldom  see  them  of  anything  like  the 
size   described    in    the  works  of  older  surgical   writers.     The 

'  [See  "  Garretson' s  Oral  Surgery,"  pp.  703-75-4.] 


376    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

largest  thut  we  ever  removed  was  about  the  size  of  a  mandarin 
orange.  As  it  arose  from  the  outer  border  of  the  upper  alveolus, 
and  occupied  a  place  between  the  cheek  and  the  gums,  it  gave 
comparative!}'  little  inconvenience,  which  up  to  that  time  had 
been  endured  by  the  patient  in  preference  to  its  removal ;  this 
latter  we  accomplished  without  much  difficulty,  as  it  was  pe- 
dunculated. The  most  common  period  for  their  appearance  is 
towards  and  about  middle  life.  In  structure  they  present  chiefly 
a  fibrous  character  intermingled  with  fibro-plastic  cells.  The 
fibres  are  collected  in  bundles  arranged  in  a  wavy  form,  spring- 
ing up  and  radiating  from  the  periosteum  of  the  alveolar  pro- 
cess, or  from  the  alveolo-dental  membrane,  and  containing  the 
cells  in  their  interstices.  Spiculae  of  bone,  or  small  nuclei  of 
bone-development,  are  frequently  found  in  the  more  central  and 
basal  portions  of  the  growth.  They  are  moderately  vascular, 
but  more  so  than  the  ordinary  type  of  fibrous  tumor.  The 
treatment  will  consist  in  their  removal  by  excision  ;  neverthe- 
less we  have  met  with  some  ot  small  dimensions  which  have 
been  more  tlian  kept  in  check  by  a  continual  application  of 
tannin.  We  had  these  under  observation  for  several  years,  and 
they  certainly  decreased  in  size ;  but  of  the  ultimate  results  we 
have  no  histf)ry.  In  their  removal  by  operation,  the  structure 
from  which  they  have  their  origin  must  be  borne  in  remem- 
brance ;  for,  to  merely  excise  them  to  the  surrounding  level 
will  be  but  to  leave  the  foundation  for  a  future  growth  of  a  more 
active  character,  and  harder  to  deal  with  than  its  predecessor. 
The  growth,  including  a  small  portion  of  surrounding  healthy 
tissue,  and  quite  to  the  surface  of  the  bone,  should  be  removed 
with  the  scalpel ;  the  bare  bone  should  then  be  scraped  or  super- 
ficially cut  away  with  a  gouge  or  bone-force[is ;  and  finally  we 
recommend  the  application  of  strong  nitric  acid,  wliich  will 
afiect  those  [)ortions  of  periosteum  which  su[)erficially  enter  the 
bone,  and  which  the  gouge  cainiot  reach.  Instead  of  scraping 
the  bone,  and  applying  the  nitric  acid,  wo  may  employ  the  actual 
cautery  ;  the  latter  is  best  suited  to  cases  where  the  exposed 
bone  presents  an  even  surface,  the  former  to  those  where  it  pre- 
sents an  uneven  and  irregular  one.  It  is  better  to  be  over-severe 
in  our  treatment  than  to  err  on  the  opposite  side,  and  subject 
our  patient  to  the  chance  of  a  recurrence  of  the  growth,  causing 


TUMORS    OF    TUB    GUM,    ETC.  377 

him  not  only  inconvenience,  but  probably  a  wretched  anxiety 
with  re<i:iir(l  to  its  true  nature 

Myeloid  Epulis. — This  is  considered  by  Heath  as  only  a 
variety  of  that  last  mentioned,  differino;  in  being  more  vascular 
and  containinii;  in  much  larger  quantity  the  polynucleated  cells 
or  myelo-plaxies  which  led  Paget  to  give  them  this  descriptive 
name.  Whether  these  elements — the  characteristic  ones  of  mar- 
row and  bone  in  an  active  state  of  growth — are  to  be  found  inva- 
riabl}'  in  all  fibrous  epules,  we  will  not  venture  to  express  an 
opinion,  but  we  fully  agree  with  those  who  consider  these  tumors 
as  having  a  deeper  origin  than  the  fibrous  variety,  viz.,  below 
the  periosteum.  They  occur,  as  a  rule,  at  an  earlier  age,  are  of 
more  rapid  growth,  and  more  readily  become  ulcerated  than 
the  former;  while  in  appearance  they  are  of  a  darker  and  more 
purple  color,  and  are  softer  to  the  touch.  The  presence  of  por- 
tions of  bone  in  their  substance  is  more  frequent  than  in  the 
fibrous  variety.  They  appear  upon  the  alveolar  processes  of 
both  jaws,  but  are,  we  believe,  more  common  to  the  lower  than 
to  the  upper  jaw.  The  treatment  will  consist  in  their  removal; 
and,  as  they  have  a  deeper  origin  than  those  last  described,  we 
must  sacrifice  with  them  more  of  the  subjacent  bone.  In  a 
case  where  we  removed  a  myeloid  growth  of  considerable  size 
from  the  right  alveolus  of  the  lower  jaw,  in  a  boy  aged  nine 
years,  we  contented  ourselves  with  removing  the  bone  only  that 
covered  the  unerupted  cuspidati  and  bicuspids,  hoping  thereby 
to  be  able  to  preserve  those  teeth  ;  and,  so  far  as  we  were  able 
to  follow  the  case,  our  object  was  attained,  and  no  return  of  the 
growth  ensued,  but  the  actual  cautery  was  freely  applied  to  the 
surface  of  the  bone  where  it  had  been  excised. 

Osseous  Growths. — Those  upon  the  alveolar  surface  are  far 
from  uncommon.  Their  most  usual  seat  is  upon  the  lower  jaw, 
on  its  inner  surface:  here  they  somewhat  interfere  with  the 
comfortable  adjustment  of  an  artificial  denture,  and  are  thus 
brought  conspicuously  under  the  notice  of  the  practitioner,  the 
patient  being  in  many  cases  quite  unaware  of  their  existence. 
Our  belief  is  that  they  correspond  to  splints  as  seen  in  the  legs 
of  horses — an  effort  of  Nature  to  strengthen  a  part  somewhat 
unduly  taxed.  The  teeth  of  these  subjects  are  generally  strong, 
and  show  evidences  of  having  been  well  employed.  The  most 
marked  cases  that  have  come  under  our  notice  have  been  in  indi- 


378    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

viduals  who  lived  largely  on  oatmeal.  Tlie  illustration  given 
(Fig.  309)  was  taken  from  a  cast  of  the  mouth  of  an  eminent 
physician;  and,  although  the  prominent  portions  of  bone  pro- 
jected considerably  under  the  tongue,  they  never  gave  rise  to 

Fig.  309. 


A  case  of  considerable  exostosis  of  the  lower  jaw. 

inconvenience.  From  their  density  of  structure  they  would  be 
difficult  to  remove,  as  much  so  perhaps  as  the  so-called  ivory  ex- 
ostoses of  the  cranium. 

Malignant  growths  occur  in  the  regions  that  fall  under  the 
province  of  the  dental  surgeon,  as  well  as  in  other  parts  of  the 
body.  Their  presence  is  no  doubt  sometimes  determined  by  the 
irritation  of  diseased  and  broken  teeth  ;  but,  even  when  we  bear 
in  mind  the  amount  of  irritation  which  may  be  thus  set  up,  it 
is  very  rare  indeed  to  be  able  to  assign  this  as  a  direct  cause  of 
cancerous  growth.  It  is  only  right  that  every  dental  surgeon 
should  be  able  to  diagnose  such  tumors  in  the  earliest  stages  of 
their  existence,  and  in  this  he  will  hardly  fail  if  he  has  paid  due 
attention  to  that  surgical  portion  of  his  course  of  study  which 
rightly  forms  an  important  part  of  a  dental  curriculum. 


DENTIGEROUS    CYSTS.  379 


CHAPTEll    XXI. 

DENTIGEROUS  CYSTS. 

Under  this  designation  are  included  two  if  not  three  varieties 
of  cystic  disease;  first,  the  occurrence  of  cysts  in  the  alveolo- 
dental  memhranc,  or  at  some  little  distance  from  it ;  secondly, 
c^'sts  which  form  in  connection  with  teeth  which  have  suffered 
impaction  or  otherwise  delayed  eruption  ;  and  perhaps  thirdly 
cysts  found  where  a  tooth  or  teeth  should  exist,  and  containinsj 
a  nuniher  of  very  imperfect,  irregularly  formed,  teeth  attached 
to  their  walls.  The  first  are  much  more  frequent  in  occurrence 
than  has  heen  generally  supposed,  and,  though  not  ahsolutely 
confined  to  the  permanent  teeth,  much  more  common  in  con- 
nection with  them  than  with  the  temporary  teeth.  Our  atten- 
tion was  turned  to  the  suhject  of  their  existence  many  years 
ago,  and  our  interest  awakened  in  it  from  watching  the  progress 
of  two  cases  operated  on  hy  the  late  Sir  W.  Lawrence,  whilst 
we  were  acting  in  the  capacity  of  dresser  to  that  gentleman. 

The  tumors  were  then  called  and  treated  as  "  hydrops  antri," 
but  we  perceived  in  their  structure,  and  more  especially  in  their 
contents,  clear  evidence  that  they  were  cystic  growths,  and  we 
shortly  afterwards  published  our  views  to  the  effect  that"  hydrops 
antri"  as  a  disease  had  no  real  existence,'  a  view  which  had 
already,  unknown  to  us,  been  advanced  by  Giraldes. 

The  situation  in  which  this  disease  most  frequently  presents 
itself  is  directly  above  the  apices  of  the  fangs  of  upper  first  or 
second  bicuspids ;  we  have  seen  it,  but  more  rarely,  over  upper 
cuspidati,  and,  on  one  or  two  occasions  only,  in  connection  with 
upper  lateral  incisors  and  upper  molars.  In  the  lower  jaw,  on 
the  contrary,  a  molar  has  been  most  frequently  associated  with 
it.  It  generally  appears  at  first  as  a  small  painless  swelling 
over  a  tooth  on  the  outer  alveolar  wall,  and  is  very  frequently 

'  Trans.  Odont.  Soc,  February,  1803. 


380 


MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 


mistaken  for  an  abscess.  As  it  increases  in  size,  it  ]:)roduces 
more  or  less  discomfort  and  inconvenience,  from  food  lodging 
between  it  and  the  cheek,  and  we  have  generally  been  told  by 
patients  that  the  swelling  has  increased  and  been  somewhat 
tender  when  they  have  suffered  from  catarrh.  [A  case  wdiere  a 
cyst  or  abscess  had  involved  the  antrum  is  s[ioken  of  on  page  237.] 
To  the  touch  the  swelling  will  yield  a  semi-elastic  feeling, 
with  no  distinct  sensation  of  fluctuation;  but  that  which  is 
most  characteristic  is  the  crackling  parchment-like  sensation, — 
"craqueraent," — felt  on  pressing  it,  and  due  to  the  yielding  of 
the  thin  outer  layer  of  bone  distended  by  its  growth  (Fig.  310). 

Fia;.  310. 


The  appearance  of  a  cystic  tumor  of  the  upper  jaw  caused  by  a  diseased  bicuspid  root. 

This,  however,  is  not  always  present  ;  the  bone  may  be  too  dense 
to  permit  movement,  as  is  generally  the  case  in  the  lower  jaw. 
At  times  a  distinct  bony  ridge  is  felt  upon  the  surface  of  the 
swelling. 

Tlie  cause  of  these  growths  is  obscure.  We  may  perhaps 
attribute  their  frequent  occurrence  in  connection  with  teeth  to 
the  liability  of  the  latter  to  conditions  producing  irritation  and 
hypersemia  aljout  their  roots.  It  may  be  observed  that  two 
classes  of  organs  in  the  body  esjiecially  liable  to  the  occurrence 
of  cysts  in  their  surroundings,  viz.,  tlie  teeth  and  the  testicles, 
are  both  of  them  developed  in  positions  from  which  they  after- 
wards migrate;  but  the  liability  of  the  ovary  and  its  surround- 
ings to  the  same  conditions  would  preclude  our  laying  much 
stress  on  this  analogy.  In  most  cases,  we  believe,  it  will  be 
found  that  these  dental  cysts  have  their  origin  in  the  cellular 
tissue  which  forms  the  sheath  to  the  nerves  and  bloodvessels  in 
their  course  to  the  teeth  ;  as,  in  the  case  of  the  bicuspids  espe- 


DENTIGEROUS    CYSTS.  381 

cially,  these  pass  throucrh  the  bone,  fornjing  the  base  and  outer 
wall  of  the  antrum  ;  tlie  develoj)nient  of  a  cyst  distends  the  bone 
oil  the  one  side  externally,  and  on  the  otlier  internally  into  the 
antrum. 

On  the  subject  of  the  treatment  of  this  class  of  cysts,  extracts 
from  a  paper  which  we  contributed  to  the  "  St.  Bartholomew's 
Plospital  Reports"^  will,  we  trust,  as  they  include  cases  actually 
treated,  prove  acceptable  to  the  reader. 

"  I  have  remarked  that  the  treatment  often  adopted  for  this 
disease  is  not  always  so  simple  as  is  actually  called  for. 

'•  The  [ilans  I  have  for  several  years  carried  out  have  in  all 
cases  in  a  very  short  time  eiiectually  cured  the  complaint,  and 
have  been,  1  imagine,  far  more  acceptable  to  the  patient  than 
those  directed  by,  at  least,  our  older  authorities  upon  the  sub- 
ject, such  as  removal  of  a  considerable  portion  of  the  outer  wall 
of  the  antrum;  removal  of  a  molar  tooth  and  perforation  of 
the  floor  of  the  antrum  through  its  alveolus  with  a  trocar;  or 
even  the  slitting  through  of  the  cheek  to  facilitate  the  first 
operation,  which  process  I  have  myself  witnessed  in  the  person 
of  a  female  some  years  ago. 

"The  process  of  treatment  I  would  recommend  can,  I  think, 
be  best  illustrated  by  selecting  three  cases  out  of  those  I  have 
met  with  during  the  present  year. 

"Case  L 

"  M.  T.,  male,  fet.  27,  out-patient  at  St.  Bartholomew's  Hos- 
pital. Bony  prominence  above  left  upper  cuspidatus  unyielding 
to  pressure.  Tooth  carious,  but  too  good  to  be  sacrificed.  Free 
incision  through  bony  wall  of  tumor  with  strong  scalpel,  escape 
of  serous  fluid,  introduction  of  tent  of  lint,  about  one  inch  of 
which  moistened  with  carbolic  acid  to  irritate  and  provoke  sup- 
puration of  cyst — lint  to  be  removed  by  patient  at  the  end  of 
twenty-four  hours.  Pain  and  swelling  ensuing,  the  lint  was 
removed  after  about  eight  hours,  but  suppuration  set  in  and 
ceased  in  about  ten  days. 

"  Case  II. 

"A  female,  ?et.  19,  in  Lawrence  Ward,  under  the  care  of  Sir 
Janies  Paget.    Swelling  on  left  side  of  mouth  above  upper  bicus- 

'  St.  Bartholomew's  Hospital  Reports,  vol.  vii. 


382 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


pid  teeth,  or  rather  their  roots.  These,  ^vith  those  of  the  first 
molar,  were  removed  under  the  influence  of  nitrous  oxide.  On 
removal  of  the  second  bicuspid  root,  there  was  a  gush  of  serous 
fluid.  Through  the  alveolus  of  this  tooth  the  lint,  as  in  the 
former  case,  was  introduced  into  the  cjst,  suppuration  set  in  in 
the  course  of  a  few  hours,  and  the  patient  was  discharged  in  the 
course  of  a  few  days. 

"  Case  III. 

"  Mr.  AV.,  tet.  24,  a  private  patient,  sent  to  me  by  my  friend 
^Ir  Pocklington,  of  Wimbledon.  This  patient  applied  on  ac- 
count of  what  lie  believed  to  be  a  gum-boil,  situated  on  the 
right  side  of  the  face,  above  the  roots  of  the  first  and  second 
upper  bicuspid  teeth.  He  informed  me  that  he  had  never  suf- 
fered pain  from  it,  but  he  applied  on  account  of  the  swelling, 
which  was  beginning  to  present  deformity.  The  second  bicus- 
pid was  carious  to  the  level  of  the  gum  ;  the  first  bicuspid 
carious,  but  capalile  of  being  preserved  by  filling.  Under  the 
influence  of  nitrous  oxide,  the  second  bicuspid  fang  was  forci- 
bly' grasped  with  a  sharp  pair  ot"  root-forceps,  which  were  well 
pressed  up.  A  large  quantity  of  serous  fluid  immediately  es- 
caped ;  and  as  the  tooth  was  removed  a  membranous  substance 
was  likewise  removed  attached  to  it.  This  proved  to  be  a  cyst 
of  almost  the  exact  form  and  size,  when  distended, 
of  a  pigeon's  egg  (Fig.  311),  which  had  been 
ruptured  in  the  process  of  removal.  The  patient 
was  congnitulated  upon  having  escaped  a  pain- 
ful and  troublesome  portion  of  the  treatment, 
jireviously  exi»lained  to  him — viz.,  that  of  hav- 
ing to  endure  the  tent  of  lint  and  the  subsequent 
8U[ipuration,  in  consequence  of  the  cyst  having 
been  removed — but  too  hastily,  for  secondary 
haemorrhage  set  in  the  same  evening,  and  Mr. 
Pocklington  had  to  jilug  the  cavity  the  tumor 
had  left.  Within  about  two  months  I  operated 
ujion  the  same  patient  for  similar  disease  upon 
A  cvHt  removed  thc  left  sidc  of  the  mouth.  This  time  it  was 
^ith  a  bicaspid  of    connected  with  the  first  upper  bicuspid,  also  a 

tbe  upper  jaw.  *  *•  '^  . 

root.     Wiien  this  was  removed,  the  cyst  did  not 
come  away,  so  the  tent  was  introduced,  and  somewhat  forcibly, 


Fig.  311. 


DENTIGEROUS    CYSTS.  383 

to  prevent  if  possible  the  unpleasant  complication  whicli  occurred 
in  his  former  case.  But  of  no  avail.  ILomorrliage,  to  which 
this  gentleman  and  several  members  of  his  family  are  liable, 
again  took  place  ;  and  Mr.  Pocklington's  services  were  again 
required  to  forcibly  ping  the  cyst,  through  the  aperture  of  the 
alveolus  of  the  first  bicuspid. 

"I  need  not  comment  further  upon  the  treatment  of  these 
three  typical  cases  than  to  observe  that  the  following  rules  may 
be  adopted.  If  the  disease  be  traced  to  a  tootli,and  that  tooth, 
though  diseased,  be  capable  of  being  saved,  we  should  oiten  the 
tumor  above  it,  and  by  suitable  means  promote  suppuration  of 
the  cyst,  which  will  end  in  a  cure.  If  the  disease  be  connected 
with  a  useless  tooth  or  root,  we  should  remove  either,  and  cause 
the  tumor  to  suppurate  through  the  alveolus.  Should  the  cyst 
come  away  witli  the  tooth,  we  may  congratulate  ourselves  and 
the  patient  that  the  best  thing  for  the  credit  of  the  former,  and 
the  best  thing  for  the  comfort  of  the  latter,  has  happened. 

"I  have  laid  much  stress  upon  making  the  cyst,  when  left, 
suppurate,  and  upon  this  ground.  I  have  seen  cystic  tumors, 
in  which  the  cyst  has  been  tapped  several  times,  and  in  which 
stimulating  injections  have  been  employed,  close  up  again,  and 
continue  to  secrete  the  characteristic  fluid  ;  but  when  once  sup- 
puration has  occurred,  healing  up  and  gradual  disappearance  of 
the  swelling  has  been  the  result." 

In  the  second  variety  an  unerupted  tooth  is  the  cause.  There 
can  be  little  doubt  but  that  the  serous  fluid  is  secreted  within 
the  dental  capsule,  which  thereby  becomes  distended.  On  cut- 
ting open  such  a  cyst  and  evacuating  its  contents — a  light  straw- 
colored  or  brownish  fluid,  which  on  settling  becomes  coated 
over  with  shining  crystals  of  cholesterine,  the  product  of  fatty 
degeneration  and  common  to  cystic  growths — the  crown  of  a 
tooth  is  found  projecting  into  it,  the  fang  being  more  or  less 
attached  to  the  surrounding  bone ;  or  it  may  ha[>ijen  that  the 
cyst  has  so  far  encroached  upon  the  bone  which  sustained  the 
tooth — its  alveolus — that  the  tooth  has  lost  its  hold  and  is  found 
lying  at  its  most  dependent  part. 

The  symptoms  of  this  form  of  dentigerous  cyst  will  be  on 
the  whole  very  similar  to  that  first  described,  viz.,  a  painless 
and  unaccountable  swelling  in  the  maxilla  at  or  near  to  the 
alveolar  process,  except  that  where  it  is  situated  a  tooth  will  be 


884        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 

wanting,  unless,  of  course,  its  origin  should  have  been  from  a 
supernumerary  one. 

Considerable  difficulty  exists  in  explaining  the  cause  of  these 
cysts.  Thus,  unerupted  or  impacted  teeth  often  exist  without 
any  such  condition  manifesting  itself.  The  most  probable  ex- 
planation to  our  mind  is  one  that  we  have  given  in  connection 
with  the  views  which  we  have  already  expressed  with  regard 
to  the  eruption  of  teeth. ^  Teeth  developed  in  abnormal  posi- 
tions become,  when  carried  to  the  surface  in  the  process  of  erup- 
tion, impacted  amongst  the  dense  and  more  stationary  layers 
of  bone  which  form  the  alveoli  of  other  teeth  ;  thus  their  pro- 
gress is  interrupted  whilst  the  surrounding  bone  still  pursues 
its  course. 

We  must  also  bear  in  mind  that  these  tumors  most  com- 
monly manifest  themselves  at  a  period  succeeding  that  when 
the  alveolar  portions  of  the  maxillte  have  been  in  a  state  of 
active  development,  in  which  they  can  readily  furnish  such  an 
amount  of  bone  as  will  perfectly  envelop  such  teeth.  By  and 
by,  as  this  activity  lessens,  such  will  not  be  the  case,  and  there 
will  be  a  tendency  to  the  existence  of  a  "  hiatus"  at  that  portion 
of  the  tooth  most  distant  from  the  nutrient  or  medullary  portion 
of  the  bone.  The  capsule  of  the  tooth,  the  remains  of  the  so- 
called  enamel-organ,  has  been  shown  by  J.  Tomes  to  be,  after 
the  calcification  of  the  enam.el,  quite  free  and  detached  from 
that  structure,  but,  being  attached  to  its  surroundings,  it  will 
be  carried  with  these  away  from  the  crown  of  the  tooth  ;  a 
space  Avill  thus  be  left,  into  which,  as  a  matter  of  course,  serous 
fluid  must,  under  atmospheric  pressure,  be  eft'used,  and  thus  a 
cyst  be  formed.  The  further  progress  of  the  disease  will  be  the 
approach  of  the  cyst  to  the  surface,  where,  if  not  interfered 
with,  it  will  eventually  evacuate  itself.  Before  this  takes  place 
it  not  uncommonly  happeiis  that  it  has  so  exposed  the  fang- 
portion  of  the  tooth,  that  the  tooth  loses  its  hold,  and  falls  into 
the  cj'st. 

The  third  variety  lias  probably  more  analogy  to  the  denti- 
gerous  cysts  found  in  ovarian  tumors  than  to  those  above  de- 
scribed :  here  we  have  evidently  a  cyst  developing  teeth  on  its 

'  On  tlic  Pathology  of  One  Form  of  Dentigcious  Cyst,  St.  Bartholomew's 
Hospital  Reports,  vol.  xii.  p.  91. 


DENTIGEROUS    CYSTS.  .  385 

internal  mucous  membrane.  The  teeth  also  in  their  irregular 
form  and  structure, such  as  appeared  in  Telhuidcr's  and  Mathias's 
cases,  before  alluded  to,  resemble  those  often  met  with  in  ovarian 
cysts.  In  both  we  have  found  teeth  destitute  of  any  pulp-cavity.' 
This  class,  as  representing  a  tooth,  might  also  be  regarded  as 
od  on  tomes. 

In  the  treatment  of  the  latter  two  classes  we  shall  adopt 
much  the  same  plan  as  in  the  first,  except  that  in  addition  to 
opening  the  cj^st  we  sliall  remove  any  tooth  or  teeth  that  it  may- 
contain.  The  third  class  have  generally  evacuated  themselves 
spontaneously,  as  will  be  the  case  with  each  variety  if  not  inter- 
fered with.  After  serous  fluid  has  been  discharged  for  some 
time,  the  secretion  becomes  clianged  in  char- 
acter, until  finally  it  appears  as  pus.  In  this  Fig.  312. 
condition  tlje  case  is  not  unfrequently  mis- 
taken for  alveolar  or  antral  abscess. 

It  has  been  said  that  alveolar  abscesses  are 
sometimes  converted  into  c^'stic  tumors,  and 
a  case  of  this  kind  is  reported  by  Salter  ;^ 
without  denying  the  possibility  of  such  con- 
version we  cannot  say  that  any  case  has 
come  before  us  to  support  us  in  entertaining 
that  view.  We  have  met  with  two  cases  Asmaiicystinconnec- 
where   abscesses   arose    in    connection    with     tioawuh  a  bicuspid  root. 

TIiG  cv*t  IiS'd.  lost  its  vi- 

roots  of  teeth  with  which  cysts  were  con-  taiuy,  iuui  had  given  rise 
nected  (Fig.  312):    the  cysts  had   evidently     to  an  abscess  la  its  m.. 

^  _    "^  -^    _  "^  _    .  mediate     neighborhood  ; 

from  their  condition,  the  results  of  inflam-  otherwise  the  cyst  had 
mation,  been  the  cause  of  the  abscesses.   Had     "^  — '-'^  ^^'^^  t^« 

'  abscess. 

these  cysts  been  left,  and  had  they  increased 
to  ordinary  dimensions,  the  inference  would  have  been  that 
they  had  originated  out  of  the  abscesses.  We  doubt  much 
whether  a  surface,  even  though  a  true  serous  membrane,  which 
has  once  secreted  pus,  and  which  remains  more  or  less  damaged 
in  consequence,  can  again  secrete  a  serous  fluid.  Indeed,  in 
attempting  to  destroy  the  serous  secretions  of  these  cysts,  we  do 
so  by  exciting  that  of  pus. 

'  Trans.  Odont.  Soc.  Nov.  2,  1863. 
i  Dental  Pathology  and  Surgery,  p.  241. 
25 


386        MANUAL    OF    DENTAL    SURGERY    AND    PATHOLOGY. 


CHAPTEU    XXII. 

DISEASES  OF  THE  ANTRUM. 

The  cavity  which  exists  in  the  superior  nuixillarj  bone,  and 
has  for  many  centuries  been  known  as  the  antrum  of  Highmore, 
is  lined  with  a  thin  covering  of  mucous  membrane,  continuous 
with  that  of  the  respiratory  tract,  through  its  small  oi)ening  into 
the  middle  meatus  nasi,  which  is  liable  to  disease,  as  are  also  its 
bony  surroundings.  We  have  recently  treated  of  cysts  in  con- 
nection with  teeth  which  frequently  occupy  much  or  the  whole 
of  the  antrum,  and  which  were  mistaken  for  a  disease,  "hydrops 
antri,"  presumed  to  have  its  origin  in  the  occlusion  of  the 
meatus  antri,  which  prevented  the  secretion  of  mucus  from  find- 
ing an  outlet.  The  normal  secretion  from  the  lining  membrane 
of  the  antrum  probably  never  accumulates  in  sufficient  quantity 
to  flow  out  of  the  cavity,  or,  indeed,  to  do  more  than  slightly 
moisten  its  surface.  When  congested  or  slightly  inflamed,  as 
in  catarrh,  it  probably,  like  the  frontal  and  sphenoidal  cavities, 
contributes  its  abnormal  share  of  mucus  or  niuco-purulent 
fluids;  but  even  on  this  point  we  have  no  direct  evidence. 
When,  however,  it  is  the  subject  of  chronic  inflammation,  the 
membrane  secretes,  and  in  al>normal  quantit}',  a  thin  purulent 
fluid  of  very  oftensive  smell,  which  is  continually  flowing  into 
the  nostril  of  that  side.  The  origin  of  this  condition  is  obscure, 
for,  though  in  many  cases  it  may  be  traced  to  the  irritation  of 
diseased  teeth,  the  roots  of  which  are  in  some  instances  in  abso- 
lute contact  with  it,  in  many  it  cannot  in  any  way  be  so  con- 
nected. The  Rymjitoms  too  are  not  clearly  marked:  a  dull 
continuous  pain  abr)Ut  the  region  of  the  maxilla  aftected,as  also 
the  orbit  of  that  side,  and  an  otfensivo  discharge  from  the  same 
nostril,  increased  in  quantity  when  the  head  is  laid  upon  the 
o[)posite  side,  are  the  most  reliable;  but  these  may  occur  when 
one  of  the  turbinated  bones,  or  its  covering,  is  affected,  and  the 


DISEASES    OF    THE    ANTRUM.  387 

antrum  of  tliat  side  is  perfectly  healthy.  With  regard  to  treat- 
ment, there  can  he  no  difference  of  opinion  U[)on  one  point,  viz., 
that,  when  the  distressing  symi»tonjs  mentioned  ahove  are  pre- 
sent, we  should  remove  all  roots  or  very  faulty  teeth  from  tiie 
superior  maxilla  of  the  affected  side.  Much  may  he  learned  as 
well  as  gained  hy  this  step,  for,  by  examining  with  a  silver 
probe  the  vacant  alveoli,  we  may  find  that  with  but  slight 
pressure  it  Avill  [lass  into  the  antrum,  when  an  odor  from  the 
probe,  or  the  reverse,  will  at  once  settle  the  question. 

For  abscess  of  the  antrum,  or  suppuration  in  the  antrum,  as 
it  is  variousl}'  termed,  may  he  mistaken  cases  where  alveolar 
abscesses  have  opened  into  that  Ciivity.  The  symjttoms  here 
are,  probably,  more  severe  pain  at  the  outset,  referred  especially 
to  an  upper  toof  h  ;  then  more  or  less  relief  followed  by  a  copious 
discharge  of  well-formed  pus  from  the  nostril  of  tliat  side.  The 
removal  of  such  a  tooth  may  be  followed  by  a  flow  of  pus  from 
its  alveolus,  either  immediately,  or  after  the  introduction  of  a 
probe  through  it  into  the  antrum. 

The  treatment  of  true  chronic  inflammation  of  the  membrane 
lining  the  antrum,  although  generally  successful  in  the  end,  is 
ver}^  tedious,  much  depending  upon  the  age  and  general  health 
of  the  patient.  Our  first  ol>ject  will  be,  to  secure  a  free  commu- 
nication between  the  cavity  of  the  antrum  and  the  njouth.  If, 
on  the  removal  of  a  tooth,  a  ]irobe  will  pass  through  the  alveo- 
lus into  the  antrum,  the  opening  should  be  enlarged  to  fully  i- 
inch.  Should  no  communication  be  eftected  with  the  probe,  or 
no  tooth  be  removed  the  roots  of  which  run  to  the  floor  of  the 
antrum,  then  an  opening  should  be  made  just  above  the  first 
molar  tooth  on  the  outer  surface  of  its  walls  :  we  do  not  recom- 
mend the  removal  of  a  sound  tooth  for  perforation  through  its 
socket.  The  instrument  best  suited  for  the  operation  is  that 
figured  (Fig.  313),  which  we  constructed  out  of  a  round  file 
sharpened  to  a  four-sided  point:  a  vulcanite  button  about  f 
an  inch  from  the  point  prevents  the  instrument  from  entering 
further  into  the  antrum,  and  endangering  the  orbit,  and  with 
it  the  operation  can  be  performed  in  a  few  seconds.  The  next, 
and  a  most  important  point  will  be,  keeping  the  opening  patent, 
as  it  will  have  a  strong  tendency  to  close  up,  and  this  will  best 
be  efi:ected  in  the  following  manner.     A  piece  of  gold  or  platiua 


388 


MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 


Fig.  313. 


tube,  about  -^-^  inch  in  diameter,  is  constructed,  and  also  a  me- 
tallic plate  to  fit  over  that  portion  of  the  jaw  in  which  the 
opening-  exists,  and  this  may  be  made  available 
for  artificial  teeth  if  required.  The  tube  is 
soldered  to  the  plate  in  such  a  position  that 
Avhen  the  plate  is  fitted  to  the  mouth  the  tube 
passes  through  the  opening  into  the  antrum, 
projecting  into  it  about  ^  inch  from  its  floor. 
As  it  is  important  to  preserve  correctly  the 
relative  positions  of  the  tube  and  the  plate  to 
the  jaw  and  the  orifice,  we  may  describe  how 
this  can  readily  be  eft'ected.  The  plate  and 
tube  being  constructed,  the  former  has  a  hole 
made  in  it  corresponding  to  that  leading  into 
the  antrum:  through  this,  when  the  plate  is 
in  the  mouth,  the  tube  is  passed  into  the  an- 
trum to  the  required  depth,  and  then  its  infe- 
rior portion,  wliich  projects  below  the  plate,  is 
attached  to  the  latter  by  some  plaster  of  Paris. 
When  the  plaster  has  set,  the  plate  and  tube 
, ,       .      are  removed  from  the  mouth  and  soldered  in 

Instrument  for  mak- 
ing'an  opening  into  the     the  correct  positions,  and  the  superfluous  por- 

*"  '""'■  tion  of  tube  is  filed  oft'  level  with  the  plate. 

The  height  of  the  tube  in  the  antrum  prevents  the  purulent 
fluid  from  runiiing  into  the  mouth,  whilst  the  open  tube  ena- 
bles the  patient  to  wash  out  the  antrum  in  the  simplest  man- 
ner possible  :  he  has  only  to  take  fluid  into  his  mouth,  close  the 
nostril  of  the  opposite  side  with  his  finger,  and  then,  by  com- 
pressing his  cheeks,  force  it  through  the  tube  into  the  antrum 
and  out  at  the  open  nostril.  As  constant  washing  out  of  the 
antrum  constitutes  a  most  important  element  in  the  treatment, 
and  as  the  process  effected  by  the  syringe  is  awkward  and  pain- 
ful to  conduct,  we  feel  sure  that  no  practitioner  who  adopts  our 
plan  will  ever  again  resort  to  the  latter. 

With  regard  to  the  lotions  recommended  for  washing  out  the 
antrum,  Condy's  fluid,  weak  carl)()lic  acid,  chlorinated  soda,  are 
amongst  those  most  employed  ;  hut  the  agent  which  in  our 
hands  has  proved  the  most  efficient  in  controlling  the  discharge 
and  [iromoting  a  healthy  condition  of  the  cavity,  is  a  dilute 
solution  of  [ihosphoric  acid  :  the  patient  should  commence  with 


DISEASES    OF    TUB    ANTRUM.  389 

a  very  weak  one,  say,  one  part  of  the  dilute  acid  to  twenty  of 
water,  and  increase  the  strength  until  it  cannot  be  borne  with- 
out discomfort.  [Tincture  of  iodine  diluted  with  water  has 
given  most  excellent  results,  both  as  a  stimulant  and  disin- 
fectant. Aromatic  suli>huric  acid  diluted  has  likewise  been 
growing  in  favor  of  late  years  with  many  practitioners  for  the 
treatment  of  difficulties  where  the  bone  is  involved.]  The  wash- 
ing-out process  may  have  to  be  continued,  and  generally,  in  true 
cases  of  antral  disease,  for  several  years;  yet  by  the  plan  recom- 
mended the  discomfort  and  annoyance  are  reduced  to  a  mini- 
mum. The  cases  reported,  which  recover  soon  after  the  removal 
of  a  carious  tooth  and  with  a  few  injections  of  the  antrum,  are, 
we  believe,  in  most  instances,  those  in  which  an  abscess  con- 
nected with  a  tooth  has  burst  into  the  antrum,  and  which  are 
thus  readily  treated.  When  the  discharge  has  quite  disap- 
peared, the  i)late  and  tube  may  be  discontinued;  or,  if  the  for- 
mer carry  teeth,  the  latter  may  be  cut  oft",  and  the  hole  into 
the  antrum  will  then  close  up.  We  liave  never  met  with  an 
instance  where  it  has  not  speedily  done  so,  but,  should  there  be 
any  such  difficulty,  we  apprehend  that  a  little  strong  nitric 
acid  applied  to  its  edges,  as  proposed  by  F.  Mason  for  small 
openings  in  the  palate,  would  no  doubt  lead  to  their  granulating 
together.  Much  larger  openings,  the  result  of  necrosis,  we  have 
closed  by  paring  the  edges  and  drawing  them  together  by  silver 
wire  sutures.  The  subject  of  closure  of  large  openings  in  the 
palate,  either  congenital  or  arising  from  disease,  by  operation, — 
staphylorapiiy, — belongs  to  the  domain  of  general  surgery,  that 
of  closure  of  the  same  by  mechanical  appliances  to  dental 
mechanics  ;  and  here  the  reader  desirous  of  information  cannot 
do  better  than  consult  the  excellent  work  of  jS'orman  Kingsley.^ 
Cases  of  irritation  set  up  in  the  antrum  by  the  lodgment  of  a 
root  of  a  tooth,  pressed  into  it  in  attempting  to  extract  the  latter, 
are  on  record.  One  so  described  by  Cattlin  led  him  to  furnish 
us  with  the  best  account  extant  of  the  form  and  variations  in 
form  of  that  cavity.  Another  case  occurred  recently  at  the 
Dental  Hospital  of  London.  In  both  the  above-mentioned  cases 
the  portion  of  root  was  removed  through  an  opening  made  into 
that  cavity,  but  we  do  not  recommend  this  being  done  unless 

'  Op.  cit. 


390    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

irritation  has  been  set  up:  we  know  a  gentleman  who  lias  had 
the  root  of  a  second  bicuspid  in  his  antrum  for  at  least  twenty 
years,  and  without  the  least  discomfort  therefrom. 

The  antrum  may  be  the  seat  of  morbid  growths  which  are 
common  to  other  parts.  Of  these  cystic  tumors  appear  amongst 
the  most  frequent:  they  may  occur  as  a  single  growth, — uni- 
locular,— or  exist  as  a  large  collection  of  smaller  cysts, — multi- 
locular.  Mucous,  fibrous,  fibroid,  and  osseous  tumors  are  also 
met  with  :  we  remember  diagnosing  an  interesting  case  of  the 
latter  whilst  actincr  as  dresser  for  the  late  Sir  W.  Lawrence.  Of 
the  above-mentioned  the  cj'stic  and  njucous  n)ay  be  generally 
extirpated  by  moderate-sized  oi)eniugs  made  into  the  antrum, 
but  the  last-mentioned  three  usually  necessitate  removal  of  the 
whole  of  that  maxilla.  [For  an  operation  devised  to  avoid  a 
scar  upoji  the  exterior  of  the  face,  the  student  is  referred  to  Gar- 
retson's  Oral  Surgery,  p.  755.] 


NERVOUS    AFFECTIONS    FROM    DENTAL    IRRITATION.       391 


CHAPTER   XXIIL 

NERVOUS  AND  MUSCULAR  AFFFXTJONS  DEPENDENT  UPON 
DENTAL  IRRITATION. 

Pain,  the  result  of  diseased  teeth,  may  be  felt  in,  and  referred 
to,  ]>arts  remote  from  the  source  of  mischief;  the  most  common 
is.  perhaps,  otalgia,  having:  its  origin  in  a  defective  molar,  espe- 
cially a  third,  of  the  lower  jaw.  When  a  patient  presents  him- 
self complaining  of  jiain  about  the  region  of  the  ear,  side  of  the 
face  and  head,  and  running  down  the  neck  of  the  clavicle,  an 
inspection  of  the  teeth  should  never  be  omitted,  as  it  will  be 
frequently  found  to  have  its  origin  in  the  tooth  specified.  On 
the  other  hand,  it  must  be  borne  in  mind  that  any  irritation  to 
a  portion  of  a  sensory  nerve,  in  its  passage  to  the  brain,  will 
cause  pain,  which  is  referred  to  the  peripheral  extremities  of  the 
fibres  irritated  ;  hence  there  may  apparently  be  pain  in  teeth 
which  are  in  no  way  the  cause  of  it.  Tlie  most  comnuni  instance 
of  the  transference  of  impressions  with  regard  to  dental  irrita- 
tion is  where  pain  in  a  carious  tooth  is  referred  to  a  sound  one, 
often  in  the  opposite  jaw.  In  rare  cases,  the  dental  irritation 
may  excite  pain  in  the  nervous  centres  of  parts  most  remote 
from  them  ;  thus  we  have  recently  had  a  case  under  observa- 
tion where  j^ain  in  a  tooth  was  invariably  accompanied  with 
that  in  one  of  the  testes.  Brunton  has  pointed  out,  that  in 
many  such  cases  it  may  be  accounted  for  by  the  irritation,  con- 
veyed to  the  centres  of  the  sensory  branches  of  the  fifth  pair, 
being  transmitted  to  those  of  the  vaso-motor  centres,  from  which 
they  are  not  far  distant,  and  thus  the  bloodvessels  in  distant 
parts  become  afi'ected. 

[Instances  of  most  curious  reflex  pain  from  tooth  trouble  are 
reported,  a  few  of  which  may  be  mentioned  as  showing  how  far 
from  the  ordinary  and  beaten  track  they  may  wander.  Dr.  Hyde 
Salter  relates  a  case  where  an  afiection  of  a  lower  molar  tooth 
caused  neuralgia  of  the  arm;   Dr.  Benjamin  Kush,  a  case  of 


o92    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

neuralgia  of  the  nates  cured  by  extraction  of  a  tooth.  M.  Petot 
cured  megrims  by  extraction  of  crowded  and  supernumerary 
teeth,  and  likewise  cases  of  difficult  and  vicarious  menstruation. 
Tiie  writer  had  a  case  of  intense  neuralgia  and  threatened  apo- 
plexy in  a  member  of  his  family,  the  exciting  cause  apparently 
being  a  capped  pul|>.  Trismus  often  threatens  during  the  erup- 
tion of  the  wisdom  teeth  ;  tetanus  and  death  are  reported  as 
following  the  pivoting  of  teeth.  The  late  Prof.  Geo.  T.  Barker 
had  a  case  of  tetanus  following  upon  replantation  of  a  tooth. 
Wry-neck  and  epilepsy  are  recorded  as  accompaniments  of  tooth 
trouble;  strabismus  and  amaurosis  are  associated  sometimes 
with  crowded  teeth.  The  tongue  persistently  furred  upon  one 
side  and  the  turning  of  the  hair  gray  have  been  caused  hy  tooth- 
ache. Insanity  is  often  aggravated  if  not  induced  by  toothaclie. 
Dr.  Mainwaring,  in  the  Lancet  (Apr.  11, 1863),  reported  a  case  of 
ulceration  of  the  cervix  uteri  as  causing  neuralgia  of  the  fifth 
pair  of  nerves.  Fiiedberg  reports  a  case  where,  after  the  removal 
of  several  aching  teeth,  one  not  complained  of  was  extracted  and 
double  neuralgia  of  the  fifth  pair  cured. ^] 

But,  besides  sensory  impressions,  the  result  of  dental  irrita- 
tion, being  thus  transferred,  the  same  irritation  may  produce 
motor-movements.  The  most  common  illustration  of  this  reflex 
action  is  that  of  which  we  have  already  treated,  viz.,  where  a 
diseased  tooth  is  accompanied  by  contraction  of  the  muscles 
whicli  close  the  mouth,  and  which  sjieedily  rehix  after  the 
tooth  has  been  removed.  Another  familiar  instance  is  the  oc- 
currence of  strabismus  due  to  teething.  In  rarer  cases  distant 
parts  are  also  affected,  as  in  the  instances  where  the  irritation 
of  teething  causes  a  permanent  contraction  of  the  muscles  of 
the  calf  of  the  leg — talipes  equinus.^  Sercombe  has  related  a 
case,  where,  through  irritation  of  the  exposed  pulp  of  a  tooth, 
contractions  of  the  uterus  were  immediately  brougiit  on:  if 
such  cases  were  common,  it  would  certainly  be  dangerous  to  re- 
move teeth  from  those  who  are  pregnant. 

'  [The  student  may  be  referred  to  "A  System  of  Dental  Snrpjery,"  by  John 
Tomes,  F.R.S.,  G.  A:  A.  Churehill,  London,  187:5,  or  Presley  Bhxki.ston,  Phila. 
Also  to  "Diseases  of  the  Teeth,"  by  Benjamin  Ward  Richardson,  II.  Bailliere, 
London,  I860.] 

2  It  must  be  borne  in  mind  that  the  conditions  referred  to  here  and  on  page 
393  may  arise  from  paralysis  of  opposing  muscles. 


NERVOUS    AFFECTIONS    FROM    DENTAL    IRRITATION.      393 
Fi-j.  314. 


Diagrammatic  representatiou  of  the  fifth  pair  of  cerehral  nerves. 

[Indeed,  the  extreme  susceptibility  of  the  uterus  to  morbid 
action,  which  in  pre2:iiant  women  is  often  most  unexpectedly 
developed,  makes  it  desirable  to  avoid  all  Operations  unless  the 
delay  will  entail  greater  danger  to  the  mother  and  foetus  than 
the  pain,  or  even  the  mental  impressions,  are  liable  to  cause. 
This  applies  equally  to  tilling  and  extracting  teeth.  The  writer 
is  reminded  of  a  case  where  tiie  mother  of  live  healthy  full- 
term  children,  after  the  excitement  produced  by  some  young 
villains,  who  made  use  of  coarse  and  beastly  lauiruage  in  the 
hearing  of  her  children,  v.as  thrown  into  labor,  and  delivered 
of  a  premature  child.  Cases  of  this  kind  are  so  numerous  that 
it  is  unnecessary  to  cite  them.  The  Mosaic  law  gave  the 
solemnity  of  its  protection  to  enceinte  women,  and  even  pre- 
scribed death  as  a  punishment  for  such  offences  as  produced  this 
trouble.] 

Intermittent,  or  clonic,  spasm  is  likewise  occasionallj'  a  con- 
sequence of  the  like  irritation  ;  and  we  now  and  then  witness 
cases  where  an  attack  of  odontalgia,  or  the  removal  of  a  tooth, 


394    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

causes  spasmodic  twitchings  for  some  time.  The  convulsions  of 
children  are  a  vevy  common  instance,  and  those  of  epilepsy  a 
more  rare  one,  of  these  ett'ects  of  dental  irritation  ;  the  former 
being  most  common  to  the  iirst,  the  latter  to  the  second,  denti- 
tion.^ 

An  opposite  condition  to  muv'^cular  contraction  may  be  like- 
wise set  up,  viz.,  where  the  nerve,  or  its  centres,  loses  the  power 
of  conveying  or  exciting  stimuli,  hence  paralysis.  Gain,  of  Bath, 
has  recorded  a  case  in  which  a  carious  tooth,  the  origin  of  sup- 
jiuration  in  the  antrum,  was  undoubtedly  the  cause  of  paralysis 
of  the  upper  eyelid  ;  for,  on  removal  of  the  tooth  and  puncture 
of  the  antrum,  the  paralysis  disappeared,  but  sight,  which  had 
been  lost,  did  not  return.  Paralysis  of  a  much  more  extensive 
character  occurs  in  consequence  of  dental  irritation,  especially 
in  teething,  as  pointed  out  by  Romberg  and  Henock,  and, 
according  to  Fliess,  is  more  common  during  the  second  than 
during  the  first  dentition.  The  symptoms,  according  to  the 
latter  writer,^  are  as  follows  :  "Its  onset  is  sudden.  The  child 
is  apparentl}'  in  good  health,  but  at  night  it  sleeps  restlessly', 
and  is  a  little  feverish.  Next  morning  tlie  arm,  or  more  rarely 
the  leg,  is  paralyzed.  The  arm  drojis;  it  is  warm  but  swollen, 
and  of  a  reddish-blue  color.  It  is  quite  immovable,  but  the 
child  sufi'ei'S  little  or  no  pain.  jS^ot  unfrequently  paralysis  is 
preceded  b}'  choreic  movements.  Sometimes  recovery  is  rai)id, 
but  at  other  times  the  limb  atrophies,  and  the  paralysis  may  be- 
come associated  with  symptoms  indicating  more  extensive  dis- 
turbance of  the  spinal  cord  and  brain,  such  as  difficulty  of 
breathing,  asthma,  palpitation,  distortion  of  the  face,  and  squint, 
ending  in  coma  and  deatli."  The  i>atiiological  anatomy  in  these 
cases  is  difficult  of  explanation  ;  the  most  probable  hj'pothesis 
is,  that  they  have  their  origin  in  disturbance  of  the  vaso-motor 
system. 

The  organs  of  sjjccial  sense  are  likewise  not  exempt  from  the 
influences  of  dental  irritation  ;  the  eye  appears  unfortunately  to 

'  True  cases  of  epilepsy  do,  however,  occur,  the  result  of  irritation  set  up  by 
diseased  temporary  teeth.  Some  of  these  have  come  under  tiie  notice  of  the 
writer,  in  Avhich  lliere  could  be  no  doubt  as  to  cause  and  effect.  Odontalgia 
from  carious  teeth  was  followed  by  true  epileptic  seizures,  which  latter  ceased 
on  the  removal  of  tlie  painful  tcetli. 

*  C^uoted  by  Brunton  in  Trans.  Odont.  Soc,  vol.  xii.  |>.  1C3. 


NERVOUS    AFFECTIONS    FROM    DENTAL    IRRITATION.       395 

be  tlic  most  liable.  Hiitcbinsoii  regards  the  blindness  to  be  re- 
flex, and  aniilogous  in  its  causation  toessential  paralysis  of  cbil- 
dren.  The  blindness  is  generally  preceded  for  a  long  time  by 
facial  neuralgia,  associated  with  toothache.  In  other  cases,  as 
we  have  met  with  them,  the  loss  of  vision  has  occurred  without 
any  attendant  pain  ;  such  was  the  condition  in  a  patient  at  the 
Dental  Hospital,  who  became  affected  with  total  blindness  in 
one  eye,  following  upon  the  pivoting  of  an  upper  incisor  tooth, 
but  who  quite  recovered  the  sight  upon  the  removal  of  the  tooth. 
Cases  of  deafness  from  the  like  cause  have  been  recorded  ;  and 
we  know  a  gentleman,  the  subject  of  facial  neuralgia,  whose 
last  attack  was  followed  by  a  total  loss  of  the  sense  of  smell. 
Finally, the  cerebral  faculties  may  suffer  from  a  similar  cause,  and 
cases  are  on  record  where  insanity  followed  severe  toothache,  and 
disappeared  upon  the  tooth  being  removed.  In  contrast  to  this 
may  be  related  the  case  of  an  insane  lady,  who  continually 
troubled  us  and  other  practitioners  to  remove  her  sound  teeth 
on  account  of  the  uncomfortable  sensations  which  she  referred 
to  them.  [The  writer  once  gave  great  offence  to  a  retired  mili- 
tary ofiicer  by  refusing  a  peremptory  written  order  of  the  latter 
to  extract  his  sound  teeth.  Softening  of  the  brain  was  soon  after 
pronounced  to  be  the  affliction  of  this  unfortunate  sufferer.] 

The  diagnosis  of  the  cause  of  neuralgia  of  the  fifth  pair  is 
extremely  difficult.  Should  a  patient  so  suffering  apply  to  us, 
our  first  care  should  be  a  thorough  inspection  of  the  teeth.  We 
must  not  simply  content  ourselves  with  a  visual  examination, but 
must  percuss  all,  especially  those  connected  with  the  divisions  of 
the  nerve  most  affected.  The  application  of  iieat  and  cold,  by  a 
jet  of  water,  may  also  aid  in  detecting  the  origin  of  the  pain.  In 
neuralgia  of  the  fifth  pair,  pressure  on  the  terminal  branches,  at 
or  about  their  emergence  from  the  bony  channels  that  they 
occup}',  will  usually  give  pain,  more  severe  in  the  case  of  the 
division  most  affected;  it  has  also  been  pointed  out  by  Trous- 
seau, tiiat  in  the  same  condition  great  tenderness  is  felt  when 
pressure  is  made  upon  the  spinous  processes  of  the  first  two 
cervical  vertebrpe.  These  two  symptoms  would  be  admiraijle 
for  diagnosis  between  odontalgia  and  true  neuralgia  but  for  the 
fact  that  the  same  conditions  are  set  up  by  carious  teeth,  at 
least  in  the  more  advanced  stages.  Our  position  will  not  be  an 
easy  one  when  a  patient  complains  of  severe  pain  referred  to  a 


396    MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

sound  tooth,  and  one  in  which  neither  percussion  nor  changes 
of  temperature  reveal  abnormal  tenderness.  We  must  not, 
however,  conclude  that  the  tooth  is  in  no  way  the  cause  of  the 
pain  ;  whilst,  on  the  other  hand,  it  may  occur  in  true  neuralgia 
that  a  tooth  becomes  tender  after  every  attack  and  yet  is  not  the 
cause  of  the  mischief.  In  the  first  case,  a  formation  of  secondary 
dentine,  involving  in  some  way  the  nerves  of  the  pulp  by  pres- 
sure, may  be  the  cause ;  we  and  others  have  removed  apparently 
sound  teeth  at  the  urgent  request  of  our  patients,  and  have 
found  such  condition  to  exist.  We  should,  however,  now,  in 
these  days  of  aneesthetics,  prefer  opening  up  the  pulp-cavity, 
and  destroying  its  contents,  to  extracting  the  tooth. 

Periodicity  in  the  attacks  may  be  some  guide  to  the  true 
nature  of  tlie  pain,  but  it  is  almost  as  common  to  neuralgia 
arising  from  dental  irritation,  as  it  is  when  due  to  chlorosis, 
ansemia,  rheumatism,  etc. 

From  the  foregoing  remarks  it  will  appear  that  we  can  offer 
but  little  tliat  will  assist  the  student  to  distinguish  odontalgia 
from  neuralgia,  having  another  origin  ;  and,  indeed,  our  laying 
down  any  clear  line  for  the  diagnosis  would  only  lead  to  his 
disapjDointment.  The  treatment  must  consequently  be  some- 
what empirical.  After  a  thorough  inspection  of  the  mouth, 
and  settino;  of  the  same  in  order  bv  the  removal  or  rectification 
of  all  likely  sources  of  irritation,  attention  must  be  directed  to 
the  system  in  general.  Thus,  should  it  be  inferred  that  the 
patient  is  chlorotic,  iron  will  be  indicated,  and  the  best  form 
for  it  is  probably  the  ammonio-citrate  ;  if  aneemic,  we  should 
prefer  the  ferro-citrate  of  quinine,  especially  if  the  conditions 
be  marked  by  much  periodicity  in  the  attacks;  in  tlie  cases 
where  we  may  expect  a  rheumatic  origin,  we  ma}'  commence 
with  alkalies,  and,  if  iiecessary,  follow  up  with  iodide  of  potas- 
sium. A  fair  trial  may  l)e  given  to  the  medicines  regarded  as 
directly  specific  for  neuralgia,  viz. — quinine,  arsenic,  bromide 
of  potassium,  chloride  of  ammonium  in  large  and  frequently 
re)'eated  doses,  and  gelsemiuni  administered  in  like  manner; 
Ijut  tlie  last  two  should  be  discontinued  after  twelve  hours  if 
no  effect  be  produced,  or  if  continued,  be  applied  only  in  much 
smaller  doses.  That  form,  and  a  not  uncommon  one,  in  which 
the  attacks  come  on  after  the  [)atient  has  been  asleep)  for  an  hour 


NERVOUS    AFFECTIONS    FROM    DENTAL    IRRITATION.      397 

or  two,  and  which  has  usually  a  dental  origin,  may  be  accounted 
for  by  local  congestion,  either  at  the  painful  spots  or  at  the 
nervous  centres.  It  is  relieved  by  sitting  up  in  bed,  or  by  walk- 
ing about,  and  a  glass  of  port  wine  acts  almost  like  magic  in 
aftbrding  relief;  all  of  these,  and  notably  the  last,  stimulate  the 
heart's  action,  which  overcomes  the  congestion  induced  by  the 
weaker  action  of  the  organ  during  sleep.  [A  toothache  recur- 
ring at  regular  intervals,  without  any  local  cause,  has  yielded  to 
quinine  used  as  an  anti-periodic;  in  one  instance  in  a  jiatient  who 
disclaimed  all  exposure  to  malarial  influence,  yet  who  during 
the  following  spring  was  attacked  by,  and  for  weeks  sufl^ered  from 
a  pronounced  case  of  malarial  fever.]  When  all  remedies  appear 
to  fail,  the  question  of  an  operation  is  open  for  consideration; 
which  will  consist  in  exposing  the  nerve  in  a  portion  of  its 
course,  and  either  stretching  or  dividing  it.  In  the  former,  we 
should,  when  able  to  do  so,  expose  the  nerve  between  the  brain 
and  the  spot  to  which  the  pain  is  especially  referred,  and,  hav- 
ing done  so,  draw  it  chiefly  towards  the  brain.  In  the  case  of 
the  fifth  nerve,  it  is  clear  that  we  could  only  so  treat  the  inferior 
dental  branch  ;  in  other  cases,  we  must  expose  it  where  it  emerges 
from  its  bony  surroundings,  and  draw  it  forwards.  In  thus 
treating  the  nerve  we  probably  alter  the  condition  of  its  vascu- 
lar supply.  To  a  somewhat  similar  action,  e.  g.  that  of  nerve- 
stretching,  we  are  inclined  to  attribute  the  temporary  relief 
often  aflbrded  by  the  removal  of  sound  teeth  in  cases  of  true 
facial  neuralgia,  the  branches  which  give  oft"  the  dental  filaments 
being  stretched  or  influenced  thereby. 

When  nerve-stretching  has  failed,  division  of  a  branch  may 
be  performed  ;  this,  in  the  case  of  the  fifth  pair,  is  again  only, 
to  any  extent,  practicable  in  the  inferior  dental,  in  its  course 
through  the  substance  of  the  lower  jaw.  The  nerve  should  be 
not  merely  divided,  but  a  section  actually  removed  from  it.  In 
other  cases,  the  nerve  may  be  divided  at  its  emergence  from  any 
of  the  three  foramina  which  give  exit  to  the  terminal  branches 
of  its  three  principal  divisions.  The  objections  to  nerve-divi- 
sion are  the  subsequent  existence  of  ansesthesia  in  the  parts  sup- 
plied by  the  distal  portion  of  the  divided  nerve,  and  the  chance 
of  the  divided  proximal  extremity  becoming  bulbous.  Severe 
neuralgic  pain  may  be  referred  to  a  spot  where  a  tooth  has  been 


398   MANUAL  OF  DENTAL  SURGERY  AND  PATHOLOGY. 

previously  removed  ;  we  long  ago  formed  the  opinion  that  its 
occurrence  was  most  probably  due  either  to  compression  of  a 
nerve-filament  by  bone  in  the  alveolus  or  in  a  cicatrix,  or  to 
bulbous  enlargement  of  the  extremity  of  a  severed  dental  nerve- 
branch.  Our  treatment  consisted  in  cutting  down  upon  the 
sensitive  spot,  freeing  the  mucous  membrane  from  the  surface  of 
the  bone,  and  removing  a  itorti('»n  of  the  latter,  wliich  operation 
we  jierformed  many  years  before  it  was  advocated  by  Gross  in 
liis  excellent  work. 


INDEX. 


ABBOTT,  Prof.  F.,  on  (k'lital  caries 
(note),  11.5 
Abscess,   tlireateninc,   treated  by  pres- 
sure, 242,  243,  247 
Absorption  mav  be  caused  by  pressure, 
131 
of  alveoli,  353 
of  organized  lymph,  how  to  effect, 

243 
of  permanent  teeth,  252 
of  temporary  teeth,  44 
Acids,  their  etfects  upon  teeth,  133 
Actual  cautery,  221 
Air,  importance  of  fresh,  for  children, 

29,  31,  ICl 
Alkalies  for  treatment  of  caries,  234 

local  application  to  teeth,  43 
Alum  objected  to  for  use  on  the  teeth, 

359 
Alveolar  abscess,  236 

artificial  fistula,  to  form,  144 
causing  salivary  fistula,  237 
opening  into  antrum,  237 
process,  fractures  of,  31U 

of  incisors,  liability  to  disease 

of,  3G9 
the  inner  plate  the  heavier, 
283 
Alveolo-dental    membrane,    inflamma- 
tion of,  235 
Amalgam,  copper,  188 

for  fillings  in  soft  teeth,  189 
how  to  prepare,  189 
mixed  metals,  190 
palladium,  186 
silver,  188 
Amalgams  for  filling  teeth,  185 

two  classes,  186 
Ana-mia.  convulsions  due  to,  33 
Antesthesia  by  chloroform,  339 
by  cold,  322 
by  electricity,  322 
by  nitrous  oxide,  322 

and  ether.  339 
how  produced,  324 
disoovery  of,  319,  320 


Anaesthesia — 

history  of,  320 
medico-legal  rules  for,  336 
the  reclining  position  in,  preferred, 
338,  344 
Anaesthetics,    chair   for    administration 
of,  343 
effect  upon  the  genitals,  338 
Anatomy  of  teeth  and  surrounding  parts, 

265 
Animals,  teeth  of,  artificially  bred,   ap- 
proach more  nearly  the  human  con- 
ditions, 23 
Antiseptics,  Prof.  W.  F.  Litch  on,  229 
Antral  trouble,  use  of  iodine  and  sulphu- 
ric acid,  389 
Antrum,  diseases  of,  386 

opened  Into  by  alveolar  abscess,  237 
suppuration  in,  386 
Aphthous  ulcers  of  the  mouth,  35 
Apoplexy  in  pulp  ca])plng,  234 
Arabs.  Bedouin,  good  teeth  of,  133 
Arsenic  a  cause  of  necrosis,  368 
as  an  antiseptic,  228 
destruction  of  dental  pulp  by,  226 
not  to  be  applied  during  inflamma- 
tion of  pulp,  249 
Arsenical   paste,    Prof.  J.   F.   Flagg's, 

226,  229 
Arsenious  acid  not  to  be  used  for  sensi- 
tive dentine,  220 
Atheromatous  cerebral  vessels  with  re- 
gard to  nitrous  oxide,  338 
Atmosphere,  attention  to  changes  of,  31 
importance  of  fresh  and  j)ure  air, 

133,  161 
of  room,  to  impregnate  with  crea- 
sote,  363 


BANDAGE  for  retraction  of  chin,  41, 
102 
Barbed  brooch,  how  to  use,  226 
Bate,  C.  Spence,  on  dental  caries.  126 
Baume,  on  eruption  of  teeth,  44 
Bedouins,  teeth  of,  133 


400 


INDEX, 


Bellows   for  resuscitation  in    apparent 

death,  334 
Bell,  T.,  on  dental  caries,  122 
Bicuspids  with  trlfurcated  roots,  59 
Bleaching  teeth,  251 
Bleeding  in  teething,  34 
Blindness  due  to  dental  irritation,  395 
Blistering  for  counter-irritation,  232 
Bone,  appearance  of  fistulas  in  diseased, 
367 
dead,  to  be  allowed  to  separate,  368 
exfoliation  of,  47,  364,  368 
liable  to  disease  over  incisor  teeth, 

369 
reproduction  of,  369 
septa,  to  remove,  311 
Branch's,  Dr.,  method  of  applying  cold, 

322 
Breathing  made  easv  by   odor  of  tar, 

364 
Breeding-in,  influence  upjon  the  jaws,  89 
Bridgman  on  dental  caries,  125 
Broca,  odontomes,  59 
Burnishers,  agate,  184 

steel,  187 
Burr-drills,  169 


CANCRUM    ORIS,    or   gangrenous 
stomatitis,  365 
Capping  pulps,  221,  223 
Carbolic  acid  for  exposed  pulps,  223 
Caries,  acid  reaction  in,  119 
chalky,  129  " 

conditions  favoring,  132,  233 
effect  of  vegetable  parasites  on.  357 
from  decomposition  in  starchy  de- 
posits on  teeth,  129 
general  course  of,  115 
in  temporary  teeth,  42 

treatment  of,  43 
on  the  increase,  1 14 
prevention  of,  161 
soft  and  hard,  129 
theorv  of  Bate,  C.  Spence,  126 
of  Bell,  T.,  122 
of  Bridgman,  125 
of  Fox,  122 
of  Hunter,  121 

of  Leber  and  Rottenstein,  1 26 
of  Robertson,  123 
of  Tomes,  J.,  123,  126 
treatment  of,  by  excision,  162 

by  filling  or  stopping,  1G6 
use  of  alkalies  locally  in,  234 

of  dental  engine  in  operation 
for,  369 
Cartwriglit,  S.,  on  irregularities  in  teeth 
{rwte),  89 


Cattlinon  the  antrum  of  Highmore,  389 
Cautery,  galvanic,  uses  of,  225 

sim])le,  by  burning  point  and  stick, 

221 
thermal,  uses  of,  366 
Cavities  for  filling,  preparation  of,  168 

spheroidal  shape  of,  1 68 
Cement  fillings,  how  to  hasten  the  set- 
ting of,  184 
how  to  use,  186 
Chair,  operating,  194 
Chalk  as  a  local  application  to  teeth,  43 
Charcoal,  objections  to  its  use  as  a  den- 
tifrice, 162 
Chill  an  indication  of  pus  formation,  243 
Chin  retractor,  41,  102 
Chinese,  teeth  of,  162 
Chloroform,  anaesthesia  by,  340 
apparatus  for,  341 
Clover's,  341 
cause  of  death  from  (note) ,  337 
Cicatrices  closing  the  jaws,  3  70 

following   lancing   of    gums    more 
easily  penetrated   than    original 
tissue,  2  7 
Clamps  for  amalgam  fillings,  192 

for  rubber-dam,  176 
Cleanliness,  impoi'tance  of,  for  children, 

3  7 
Clendon,  on  treatment  of  cicatrices,  371 
Closing  of  spaces  resulting  from  extrac- 
tion of  incisor  teeth,  1 12 
Clover's  apparatus  for  chloroform,  341 

for  nitrous  oxide  and  ether,  339 
Coffin,  expansion  plates  of,  93 
C^old  for  periodontitis,  242 

for  producing  anesthesia,  322 
Coles,    Oakley,    on   abnormal   maxilla? 

(note),  91 
Combinations  for  color  in  fillings,  215 
Compound  fillings,  objections  to,  203 
Concussion  of  teeth,  108 
Congestion  of  the  gums,  353 
Contracted   dental  arch,   C.   S.  Tomes 

on,  92 
Convulsions,  bleeding  in,  etc.,  25,  34 
due  to  anasmia,  33 
in  teething,  23 
lancing  the  gums  for,  25,  32 
Creasote,  nascent,  for  teeth,  363 
Crowning  teeth  roots,  244,  257,  264 

Drs.  (iates  and  Bonwill's 

method,  262 
Dr.  Richmond's  method, 

259 
Prof.  Fliigg's  method,  262 
Cryor's,  Dr.  M.  H.,  d(;vice  for  bands  to 
j)rotect  teeth  from   injury   when   un- 
dergoing pressure  by  jack-screws,  107 


INDEX. 


401 


Cusps  and  roots  of  toeth,  302 
Cutaneous  eruptions  in  teething,  24,  35 
Cyanosis  with  regard  to  nitrous  oxide, 

338 
Cysts,  bony,  use  of  iodine  and  sulpliuric 
acid  for,  389 
dentigerous,  379 


DARWIN  on  ill-developed  maxillaj, 
89 
Deafness  due  to  dental  irritation,  395 
Decay  by  denudation,  130 
Deciduous  teeth,  gemination  of,  39 

restoreil  to  ])()sition  after  being 

driven  into  the  bone,  110 
to  be  retained,  301 
to  extract,  300 
Deficiency  in  perniaTient  teeth,  61 

in  temporary  teeth,  39 
Dental  arch,  expansion  of,  92 
Dental  engine,  1G7 

to  polish  with,  358 
Dental   pulp,   abnoru\al   conditions  of, 

234 
Dentifrice,  359 

Dentifrices,  objections  to  insoluble  mat- 
ters in,  162 
Dentigerous  cysts,  55  (note),  379 
Dentine,    cutting   sensitive,    causes    in- 
creased How  of  saliva,  1 9 
for  capping  exposed  pulps,  221 
secondary,  1 20 
Dentition,  eruption  of  children's  teeth 
earlier  in  the  United  States  than 
in  Eurojje,  22 
exceptional    cases   of    third   teeth 

may  occur,  1  7 
lancing  for  too  rapid  presentation 

of  teeth,  25 
relief  of  pain  following  lancing,  26 
replacement  occui-s  but  once  in  tlie 
higher   mammals,    according   to 
Owen,  17 
second,  time  of  completion,  48 
See  Teething. 
Development  of  teeth,  17,  47 
Diagnosis  of  exposed  pulps,  313 
of  periostitis,  313 
of  pus  formation  by  a  chill,  243 
Dlan'ha'a  in  teething,  24 

treatment  of,  27 
of  infants,  lancing  the  gums  in,  29 
treatment  of,  in  children,  32 
Dickey,  Dr.  N.  L.,  case  of  dentigerous 

cyst,  55  (note) 
Dickinson  on  teething,  36 
Difficulties  in  extraction,  302 

due  to  forms  of  teeth,  303 
26 


Difficulties  in  extraction — 

from  closure  of  jaws,  306 
from  impaction  of  teeth, 
307 
in  filling  teeth,  216 
Dilaceration,  113 
Discovery  of  anipsthesla,  320 
Diseases  of  infants,  lancing  the  gums,  29 
Disinfectant  mouth  wash,  368 
Dislocation  of  jaw,  311 

of  teeth,  l'08 
Dress  for  children,  31,  37 
Drilling  openings  into  pulp  cavities  for 
putrescent  pulps,  231 


ELECTRICITY    as    an    anajsthetlc, 
322 
Elevator,  application  of,  297 
forms  of,  295,  296 
how  to  use,  297 
principles  of,  295 
Enamel-cutters  or  chisels,  163 
Enamel-nodules,  60 
Enema  for  dysentery,  32 
Engine,  dental,  167,  170 

points,    to    prepare,    for    cleaning 
teeth,  358 
Epilepsy  during  second  dentition,  52 

due  to  dental  irritation,  293 
Epulis,  fibrous,  375 

myeloid,  37  7 
Erosion  of  teeth,  48,  130 
Eruption  of  permanent  teeth,  49 

earlier    in    the    United 
States,  51 
of  teeth,  how  effected,  39 
of  temporary  teeth,   earlier  In  fe- 
males, 22 
order  and  periods  of, 

20 
prior  to  birth,  20 
of  third  molars  late  in  life,  G3 
Eruptions,  cutaneous.  In  teething,  24 

treatment  of,  35 
Esmarch,  operation  of,  371 
Escjuimaux,  teeth  of,  161 
Ether  as  an  anaesthetic,  339 
Ether-spray,  322 
Ethidene-dichloride,  344 
Exanthemata  marking  teeth,  56 
Excavators,  forms  of,  etc.,  169 
Excision  in  caries,  162 

of  exposed  roots  of  teeth,  43 
Exercise  in  tlie  open  air  with  an  object, 

161 
Exfoliation  of  bone,  46,  364 
Exostosis  of  teeth,  254 

causes  of,  254 


402 


INDEX. 


Exostosis  of  teeth — 

consequences  of,  255 
of  the  jaws,  37  7 
Expansion  and  development  of  jaws  by 
mastication  of  hard  food,  104 
of  dental  arch,  92 
Experiments  with  regard  to  caries,  128 
Extraction  for  relief  of  crowding  third 
molars,  52 
hiemorrhage  after,  314,  316 
objected  to  during  pregnancy,  335, 

393 
of  deciduous  teeth,  82 
of  roots  by  the  elevator,  295 
bv  the  forceps,  290 
by  the  screw,  291,  300 
rules  for,  290 
of   sixth    year   molars    may   cause 

irregularity,  98 
of  teeth,  96,"  267 

anatomy    of    teeth    and    sur- 
rounding parts,  265 
caution   with   lateral   incisors, 

281 
consideration  of  patient,  265 
difficulties  in,  302 
for  iiTCgularity,  96 
forms  of  forceps,  270 
movement  for,  280,  285 
position     of     the      operator's 

hands,  280 
rules  for,  264 
tables  to  guide  in,  289 
with  the  forceps,  268 
with  the  key,  267,  268 
with  the  screw,  291 
of  temporary  teeth,  300,  301 
painless,  by  cold,  322 
under  an  amesthetic,  329 
when  to  lance,  298 


FAINTING,  to  send  the  blood  to  the 
brain,  344 
Eang-fiUing,  operations  for,  227 
Fangs,  excess  of,  in  number,  39,  58 
exposure  of,  through  the  gums,  42, 

367 
forceps  for  extracting,  290 
Feeding,  artificial,  for  infants,  28 
Fig-poultice,  objection  to,  247 
P'illing  fangs  of  te(!th,  228 
teeth,  difficulties  in,  216 
materials  for,  166 
op(!rations  for,  166 
plan  for,  210 
to  prevent  progress  of  erosion, 

131 
with  amalgams,  185 


Filling  teeth — 

with  gold,  193 
Filling  materials,  combinations  for  color, 

215 
Filling,  renew  if  moistened,  210 
Fillings,  how  to  make  of  gold,  1 50 
of  gutta-percha,  179 
watertight,  232 
Finger,    to    protect,    when    using    the 

elevator,  297 
Fistula,  artificial,  to  form,  244 
Fistulaj  from  diseased  bone,  367 

from  diseased  teeth,  36  7 
Flagg,  Prof.  J.  Foster,  arsenical  paste, 
220,  229 
ca]is  to  prevent  occlusion,  76 
condensing  forceps,  157 
correction  of  irregularity,  75 
pivoting  teeth,  262 
water-bath,  182 
Flexible  rubber  syringes,  objection  to, 

172 
Flour  for  diarrhcea  of  infants,  29 
Flower,  on  absence  of  teeth  (note),  63 
Food,  artificial,  for  infants,  27 

how  to  prepare,  28,  30 
Forceps,  compressing  or  plugging,  198 
dividing,  293 
excising,  310 
extracting,  for  roots  of  teeth,  290 

general,  268 
for  condensing.  Prof.  Flagg' s,  157 
for  teeth,  forms  of,  270,  288 
for  temporary  teeth,  300 
the  leaden,  283 
Formula  of  permanent  teetli,  49 

of  temporai-y  teeth,  19 
Fracture  of  jaws,  in  extraction,  311 
treatment  of,  84 

b}'  Gunning's  splint,  85 
by  Hammond's  splint,  86 
temporary  splints  lor,  87 
of  teeth,  110 
Fractured  teeth,  union  of,  112 

tooth,  imj)acted,  1 1  2 
Frankland,  on  action  ofnitrous oxide,  324 

on  artificial  milk  {nolc),  30 
Freezing  before  extraction,  322 


GALVANIC  action  between  fillings, 
212 
Gangrene  of  dental  pulp,  121 

dry,  228 
Gangrenous  stomatitis,  365 
Garretson,   Prof.  J.  E.,  allowing  dead 
bone  to  separate,  368 
case   of  nfproduction   of  jaw- 
bone, 369 


INDEX. 


403 


Gan-etson,  Prof.  J.  E. — 

salivary  fistula,  237 
use  of  burring  instrument  for 
operation  on  bone,  3G9 
Gemination  of  permanent  teeth,  58 

of  temporary  or  deeiduous  teeth,  39 
Genitals   last   aliected  by  anaesthetics, 

338 
Gold,  fillinn  with,  may  be  too  tedious  for 
patient,  193 
for  filling  teeth,  193 

cohesive.  203 

objection  to,  215 
non  cohesive,  194 
precipitated,  20K 
how  to  prepare  and  fill  with,  150 
Goodsir,  jjrimitive  dental  groove  of,  18 
(Grooves  for  retaining  filling,  212 
Grouy)S,  teeth  erupted  in,  20 
Gumboil,  consequences  of,  42 
Gums,  congestion  of,  353 
hypertrophy  of,  374 
irritation  of,  by  tooth-brush,  a  cause 

of  caries,  130 
lancing  of,  in  teething,  25,  32 
the  health  line  of,  24G 
(Running,  interdental  splint  of,  85 
Gutta-percha  and  cement  fillings,  180 
fillings,  how  to  finish,  183 
for  fillings,  179 
how  to  avoid  pain  from  heat,  183 


HAEMORRHAGE,  alveolar,  314 
primary,  314 
secondary,  314 
to  arrest,  314",  316 
Haimorrha-iic  diathesis,  315 
Hammond's  splint,  86 
Hand-piece  for  dental  engine,  Dr.  H. 

C.  Register's,  1  70 
Health  line  of  the  gums,  246 

of  patient  impaired  by  tedious  ope- 
rations, 193 
Heat,  242 

Heath,   C,    on  hypertrophy   of  gums, 
374 
on  myeloid  epulis,  37  7 
Heat-stroke,  to  prevent,  35 
Hermann,  on  nitrous  oxide,  324 
Honeycombed  teeth,  55 
Horseback  exercise  in  the  open  air,  161 
Hot-air  syringe,  252 
HuUihen,  operation  of,  231 
Hunter,  on  decay  of  teeth,  121 
Hutchinson,  J.,  on  blindness  due  to  den- 
tal irritation,  395 
on  honeycombed  teeth,  56 
on  sy[)hilitic  teeth,  57 


Hyperostosis  of  fangs,  253 
causes  of,  254 
consequences  of,  255 

Hypertrophy  of  gums,  .374 

Hvsteria  with  regard  to  nitrous  oxide, 
338 


ILLUMINATOR,  mouth,  Hart's,  255, 
310 
Impacted  teeth,  307 

conse([Mences  of,  384 
Impressions,  method  of  taking,  G8 
Indians'  mode  of  cleansing  the  teeth,  162 
Inrtammation  of  dental  periosteum,  235 
of  dental  pulp,  120 
of  the  gums,  359 
Injuries  to  teeth,  108 
Insolation,  treatment  to  prevent,  35 
Instruments,  selection  of,  134 
Insuttlation  by  bellows,  334 
Intermaxillary  bones,  growth  of,  50 
Iodine  for  blistering,  232 

for  treatment  of  oidium  albicans, 
360 
Irregularities    in    permanent   teeth,    in 
form,  55 
in  number,  60 
in  position,  63,  88 
in  size,  54 
in  temporary  teeth.  38 
Irregularity   of  teeth,    bands  for  teeth 
undergoing  pressure  by  jack- 
screws,  107 
caps   to  prevent   occlusion   of 

teeth,  76 
caused  by  extraction  of  sixth- 
year  molars,  98 
by  tonsillitis,  89 
correction    of,    not    to    be   at- 
tempted until  dentinification 
of  the  ends  of  the  roots  is 
completed,  74 
Dr.   L.  Jack's   observation  of 
extraction  of  sixth-year  mo- 
lars, 98 
Dr.  G.  W.  Neidich's  case,  45 
Drs.    J.    W.    White    and  N. 
Kingley's     observation      of 
mouths  of  idiots,  92 
im])ortance  of  retaining  decid- 
uous teeth  for  prevention  of, 
82,  104 
ligatures  and  knots  for  treat- 
ment of,  75 
not  common  in  idiots,  92 
Prof.  J.  F.  Flagg's  caps  to  pre- 
vent occlusion,  76 
method  of  correction,  75 


404 


INDEX. 


Irregularity  of  teeth — 

Trol".  J.  n.  ]McQiiillen-s  bar 
ibr  correction  of,  76 
cajjs  to  prevent  oeelusion, 
7G 
Prof.   S.  H.  GuiHbrd's  clasps 

for  correction  of,  79 
rubber  plate  for  retaining  teeth 
in  position,  82 
springs  tor  correction  of, 
75 
torsion  by  forceps,  73 
by  ligatures,  7  7 
Irritation  in  dentition,  object  of  (?Jo/e),  23 


JACK-SCREAY,  for  expanding  den- 
tal arch,  94 
Jack's,  Dr.  L.,  matrices  and  pluggers, 

155 
tTarvis',  Dr.,  separators,  217 
Johnson's,  Dr.  J.  G.,  views  on  the  use 
of  anajstheties,  336 


KEY  instrument  for  extraction,  2G7 
Kingsley,    Dr.   Norman    AV.,    on 
oral  d'eformities,  107,  389 
Knife  and    Ibrk,    influence    of,   on  the 
teeth,  132 


LA^MP  for  -working  gutta  percha  for 
filling,  182 
J^ancing  tiie  gums  as  a  remedy  for  eom- 
])lications  in  diseases  of  in- 
fants, 29 
how  to  perform  the  operation, 

34 
in  teething,  25,  3  2 
of  older  cliildren,  51 
relief  afforded  by,  in  dentition, 

26 
seems  to  assist  abnormal  erup- 
tion of  teeth,  25 
should  be  thorough,  26 
to  reduce  nervous  symptoms, 

34 
when  to  perform  it,  215 

for  extraction,  298 
Leaden  extractor,  283 
Lelicr  and  Rottenstein,  on  (viries,  125, 

126 
Jjcptothrix  in  caries,  119,  126 
J>ini(?- water  for  mouth-wash,  43 
IJning  cavities,  202 

Litcli,  Prof.  W.  v.,  on  antiseptics,  229 
J>ord's,  Dr.  Bi-nj.,  pluggers,  153 
J>oss  of  teeth,  premature,  354 


Luxation  of  teeth    and   successful   re- 
placement, 109 
Lyons,  1.,  on  fracture  of  jaws,  86 
on  necrosis  of  jaws,  368 


MAGITOT,  on  caries,  125 
on  replantation,  347 
Malarial  toothache,  397 
Mallet  for  filling  teeth,  197 
automatic,  197 

objection  to,  198 
dental  engine,  207 
electro-magnetic,  209 
Palmer's,  Dr.C,  lead,  158 
pneumatic,  198,  207 
Mason,  F.,  on  small  openings  in  palate, 

389 
Matrices  and  pluggers.  Dr.  L.  Jack's,  1 55 
for    a])proximal    fillings.     Dr.    L. 
Jack's,  214 
Maxillaj,  development  of,  88 
Darwin  on,  89 
McQuillen,  Prof.  J.  H.,  caps  to  prevent 
occlusion,  76 
reproduction     of     nerve- 
cells,  109 
restoration  of  function   in 
ablated  cerebrum,  109 
Medico-legal  aspect  of  anajsthetics,  336 
Micrococci,  in  caries,  119 
Milk,  ass's,  30 

cow's,  casein  of,  as  compared  with 
human  milk,  28 
preparation  for  infants,  28,  31 
goat's,  30 
imitation    of    human,     Frankland 

(note),  30 
of  woman,  ass,  cow,   etc.,  analysis 

ot'  (nnt(/),  30 
substitutes  for  human,  30 
Mitsciieriich,  on  replantation,  345 

on  transplantation,  352 
]\Ioisture  wliiic;  filling,  210 
Morrison's  dental  engine,  166 
Mouth  mirror,  139 

Muscular   contraction   dependent  upon 
dental  irritation,  306,  392 


NECROSLS  caused  by  arsenic,  368 
of  cementum,  246,* 250 
of  maxilla-,  367 

following  fevers,  364 
of  permanent  teeth,  108,  250 
of  temporary  teeth,  42 
Neidich's,   Dr.  (j.   II.,   case  of  iri-egu- 

larity,  45 
Nerve,  rupture  of,  in  extraction,  313 


INDEX. 


405 


Nerve-streti'hiiig  for  neuralgia,  ."0  7, 
Nervous  atleotions  dependent  upon  den- 
tal irritation,  391 
disturbance,  lancing  for,  34 
Neuralgia  of  the  tifth  pair,  3!)5 
Nitrogen  as  an  ainestlietic,  324 
Nitrous  oxide,  aj)i)aratus  for  adminis- 
tering, 3 '2  7 
as  an  ansesthetic,  323 
deaths  from,  324 
mode  of  administering,  329 
of  j)reparing,  325 
of  storing,  32G 
physiology  of  effects  of,  324 
safety  of,  323 

symptoms  of  danger  with,  333 
Nodules  of  enamel  on  teeth,  CO 
Non-cohesive  gold,   difierence  from  co- 
hesive, 203 
for  tilling,  215 
Non-conductors,  for  lining  cavities,  20^ 


OCCLUSION  of  teeth  in  i«?riodontal 
irritation,  255 
Odontitis  infantum,  35 
Odontoblasts,  function  of,  218,  253 
Odontomes,  59 

Oidium  albicans,  treatment,  35 
by  iodine,  3G0 
Opium  in  diarrhoea,  31,  32 

in  dysentery,  32 
Order  of  eruption  of  permanent  teeth, 
49 
of  temporary  teeth,  20 
Organized  lymph,  how  to  cause  absorp- 
tion of,  243 
Osseous  union  of  the  jaws,  370 
Owen,   Prof.   R.,   on  dentition  of  ele- 
phant (ni)te),  47 
replacement  of  teeth  occurs  but 
once  in  the  hiiiher  mammals, 
17 
Oxychlorlde   of  zinc  for  filling  teeth, 
183 


PAGET,  Sir  J.,  diagnosis  of  impacted 
teeth,  309 
Pain  after  extraction,  313 
in  stopped  teeth,  231 
Painless  excavation,  171,  220,  221 
Palmer's,  Dr.  C,  method  of  wedging, 

21G 
Papillary  tumor  of  the  gum,  373 
Paralysis  due  to  teething,  394 
following  extraction,  313 
Para.sites,  in  cavities  of  carious  teeth  an 
accidental  accompaniment,  IIG 


Periodontal  irritation,  occlusion  in,  255 
Periodontitis,  chronic,  245 
treatment  of,  24  7 
ether  spray  for,  242 
extraction,  objection  to,  242 
hot  water  for,  242 
pathology  of,  238 
symptoms  of,  235 
treatment  of,  241 
Periostitis,  to  diagnose,  313 
Permanganate    of    potassa    for    mouth- 
wash, 3  as 
Peroxide  of  tin,  for  polishing  teeth,  1G3 
Pei-spiration,   imperceptible,   danger  of 

retention,  3  7 
PHuger's,  Dr.  H.  E.,  restoration  of  pulp 

tissue  in  teeth,  109 
Phthisis  in  regard  to  nitrous  oxide,  33G 
Pitted  teeth,  5C 
Pivoting  teeth,  257 
Plates,  i-egulation,  70,  73 

treatment  of  fractures   of  jaw  by, 
84 
Pluggers,  Dr.  L.  Jack's,  155 

Dr.  Benj.  Lord's,  153 
Polishing  teeth  with  peroxide  of  tin,  163 
Polypus  of  dental-pulj),  225 

of  gum,  3  72 
Pregnancy,  a  cause  of  abortion  in,  131 
effects  of,  on  the  teeth,  233 
unfavorable    time    for    operations, 

335,  393 
with  regard  to  nitrous  oxide,  335 
Pressure    in  threatening  abscess,    242, 

243,  247 
Primitive  dental  groove,  Goodsir,  18 
Pulp  ca])ping,  ajjoplexy  from,  234 
destruction  of,  225 
exposure  of.  by  disease,  120,  222 

traumatic,'  110,  221 
general    abnormal    conditions    of, 

234 
inflammation  of,  120 
removal  of,  227 

treatment  of,  when  exposed,  222 
ulceration  of,  120 
Pulps,  exposed,  to  diagnose,  313 
Pui'gative  for  infants  in  diarrluea,  32 
Pus  formation  accompanied  b^'  a  chill, 

243 
Pyrophosphate  of  zinc,  for  filling  teeth, 
'l85 


REFLEX  pain  from  teeth,  391 
Relative  liability  of  teeth  to  caries, 
99 
Removal  of  temporary  teeth  for  crowd- 
ing, G7,  103,  104 


406 


INDEX, 


Rci)laiitation  of  teeth,  34") 
Reproduction  of  nerve-cells  of  cerebrum 
of  pigeon.  Prof.  J.  H.   McQuil- 
len's  case,  109 
of  pulp-tissue  of  teeth,  Dr.   H.  E. 
PHuger's  case,  109 
Respiration,  soothing  effect  of  tar,  364 
Respiratory  organs,  affected  by  teeth- 
ing, 24 
Retaining  grooves,  212 

points  for  fillings,  204 
Rickets,  with  respect  to  delayed  denti- 
tion, 22 
Riggs'  disease,  3.55 
Robertson,  W.,  on  dental  caries,  123 
Rogers,  Claude,  case  of  division  of  jaw 
by  a  plate,  371 
saliva-ejector,  172 
Roots  of  teeth,  extraction  of,  290 
Rotary    movement    for    extraction    of 

teeth,  280 
Rotation  or  torsion  of  teeth,  46,  73,  77 
Rottenstein  and  Leber,  on  caries,  125, 

126 
Rubber-dam,  Barnum's,  172 

appliances  for,  etc.,  174 
clamps,  Dr.  Ambler  Tees',  178 
how  to  cut  and  apply,  178 


SALIVA,     abnormal    increase    of    in 
teething,  18 
offices  of,  IS 

pain  from  cutting  sensitive  dentine* 
augments  the  How  of,  19 
Saliva-ejectors,  172 
Salivar}-  calculus  or  tartar,  355 

vegetable  parasites,  357 
fistula.  Prof.  Garretson's  case,  237 
Salivation,  results  of,  366,  369 
Salter,  on  necrosis  after  fever,  363 
on  papillary  tumor,  3  73 
on  "  warty  teeth,"  59 
Savages,    teeth    of,    a  guide    to    their 

chances  of  life,  133 
Scalers  for  removing  tartar,  358 
Scoops  for  excavation,  171 
Screw,  how  to  use,  291 
Screws  for  extraction,  291,  300 
Scurvy  of  the  gums,  353 
Secondary  dentine,  120 
Sensation  in  teeth,  object  of,  219 
Sensitive  dentine,  how  to  excavate,  171 
Sensitiveness  of  dentine,  218 
Separation  of  teetii,  pro(!(!Sses  for,  21 G 
Separators,  Dr.  .Jarvis',  217 
Septa  of  bone,  to  remove,  311 
Se(|U(!stra  not  to  be  removed  before  de- 
tached, 368 


Sexual  selection,    influence  of,   on   the 

jaws,  90 
Shelley,  Hubert,  on  exostosis,  254 
Shrinkage  of  tooth  in  di-ying,  233 
Skulls,  collection  of,  at  Hythe,  88 
Sloughing   of   gum   over    an   erupting 

tooth,  35 
Smell,  case   of  loss  of,  with  neuralgia, 

395 
Smoke  of  bituminous  coal  for  allaying 

irritation  of  respiratory  track,  364 
Softening   of  the   brain,    trouble   with 

the  teeth  from,  395 
Space  between  teeth,  how  to  gain,  216, 

217 
Spatulas,  181,  184 

Spheroidal  form  with  regard  to  amal- 
gams, 191 
shape  for  cavities  for  filling,  168 
Splints,  temporary,  for  fracture  of  jaws, 

■  87 
Starch  enema,  32 

fermentation  of,   a  cause  of  caries 

of  teeth,  129 
raw,  for  abraded  surfaces,  35 
for  chafing,  35 
Stomach  teeth,  49 
Stopped  teeth,  pain  in,  231 
Stopping  teeth,  see  Filling  teeth. 
Stuffing  teeth,  nee  Filling  teeth. 
Supernumerary  teeth,  40,  58,  60,  61 
Syphilitic  teeth,  20,  57 
Syringe,  glass,  metal,  celluloid,  172 
hot  air,  252 
objections  to  flexible  rubber,  172 


TABLE    of    eruption    of    permanent 
teeth,  50 
of  temporary  teeth,  22 
of  operations  in  extraction,  289 
of  relative  liability  to  caries,  99 
Talc  for  coating  cement  fillings,  184 
Talipes   equinus,   due  to  teething,    24, 

392 
Tartar,  or  salivary  (-alculus,  355 
Teeth    acliing    from    softening   of    the 
brain,  395 
alum  not  to  Ite  used  on  the,  359 
ai)pearance  of  fistula;  over  diseased, 

36  7 
bleaching  of,  251 
commencement  of  development  of. 

17 
erosion  of  roots,  48 
exposed  pulps,  to  diagnose,  313 
extraction  of,  264 
for  crowding,  53 
of  temporary,  300,  301 


INDEX 


407 


Troth— 

I'on.-eps,  forms  of,  270,  288 

tilt'  It'adi'ii,  28:1 
gemination  of  <U'ciiluou?,  30 

of  permanent,  58 
markings  of,  iVom  exanthemata,  50 
oechision    of,    in    abnormal   condi- 
tions, 255 
of  artifieially  bred  animals  approach 
more  nearly  the  conditions  ibund 
in  man,  23 
of  savages  a  guide  to  their  chances 

of  life,  133 
permanent,  eruption  of,  49 
honeycombed,  55 
irregularities  in,  54 
nund)er,  ibrnuila,  etc.,  of,  49 
period  of  eruption   in  United 

States,  51 
syphilitic,  oG 
pivoting,  257 
rcHex  pain  from,  391 
relative    projjortions   of  roots   and 

crowns,  302 
retention  of  bicuspids,  02 

of  third  molars,  03 
roots,  importance  of,  for  crowning, 

244 
supernumerary,  01 
temporary,  absence  of,  39 
absorption  of,  43 
classification  of,' 20 
diseases  of,  40 
erupted  earlier  in  girls,  22 

prior  to  birth,  20 
excess  of,  39 
extraction  of,  300 
geminated,  39,  58 
necrosed,  not  absorbed,  48 
number,  arrangement,  etc.,  of, 

19 
order,  periods  of  erujition,  etc., 

of,  20 
retarded  eruption  of,  20 
the  cingulus  of,  302 
the  stomach,  49 
third  sets  of,  03 
to  clean  with  the  engine,  358 
treatment  of  unusually  lai-ge  inci- 
sors, 55 
two  sets  of,  object  of,  1 7 
vegetable   parasites,   effect   of,    on 

the,  357 
wedging,  210,  217 
Teething,  conditions  in,  abnormal,  23 
normal,  22 
convulsions  in,  33 
cutaneous  eruptions  in,  35 
deaths  directly  from,  24 


Teething — 

maiuigement  of  children  during,  25 
sloughing  of  gum  in,  35 
Temperature  lor  nursery,  31 
Theories  of  dental  caries,  121 
Thnish  in  infants,  300 
Thumb-sucking,  a  cause  of  irregidarity, 
40,  83 
result  of,  40 
Tomes,    C.    S.,    on    contracted   dental 
arch,  92 
on  dental  caries,  1  25 
J.,  on  absorption  of  teeth,  48 
on  dental  caries,  123 
on    relative    liability    of    the 

teeth  to  caries,  99 
"zone  of,"  117,  129 
Tonic   treatment    by    out-door   work, 

101 
Tonsillitis  as  a  cause  of  contraction  of 

dental  arch,  89 
Toothache  drops,  314 

malarial,  397 
Tooth,  aching,  not  to  be  extracted,  314 
Tooth-brush,   as  employed  by  Chinese, 
102 
effects  of  a  stiff"  brush  on  necks  of 

teeth,  130 
value  of,  43,  102 
Tooth-extractor,  the  leaden,  283 
Tooth-  pulp,    arsenic   objected   to   when 

inllamed,  249 
Tooth,    the   extracted,    the   best   com- 
press, 310 
Torsion,  immediate,  by  forceps,  46 
for  irregularity,  73,  77 
of  teeth,  73 
Translucent   zone   under   gold   fillings, 

117 
Transplantation  of  teeth,  34  7 
Treatment  of  caries  by  excision,  103 

by  filling,  100 
Trousseau,  on  neuralgia,  395 

works  of,  recommended,  30 
Tumors,  a  cause  of  irregularity,  40,  83 
of  the  gum,  372 
upon  the  jaws,  375 
Typhoid  fever,  lowered  vitality  of  teeth 
'in,  108 


TTLCERATION  of  dental  pulp,  120 
U  of  the  gum,  300 

aphthous,  300 
strumous,   mercurial,  syphilitic, 
300 
Ulcerative  stomatitis,  301 
Ulcers,  aphthous,  of  mouth,  treatment, 
35 


408 


INDEX, 


VASCULAR  tumors  of  the  gum,  373 
Ventilation,  importance  of,  in  chil- 
dren's apartments,  31 
Yincjrar  for  diarrhoea,  32 


Wedginir,  rapid,  216 

teeth,  how  to  perform,  217 
Wedl,  C,  on  dental  caries,  125 
on  dilaceration,  113 


Vomiting   of    infants   not   to    be    con- i  Wells,  Dr.  H.,  use  of  nitrous  oxide,  32U 
founded  with   mere  regurgitation   of !  West  on  convulsions,  24 
food,  24  Avorks  of,  recommended,  36 


V-shaped  dental  arch,  100 


AVilhite's,  Dr.  J.  P.,  use  of  ether,  320 
Wood-smoke  for  teeth,  363 


'll^'ALLS    of  cavities    may  crumble 

VY      under  ])ressure,  215  :  r71NC   oxychlorides  for  filling  teeth, 

AA'armth  for  children,  31  ;  Zi  183 

Water-bath    ibr    gutta-percha  fillings,  ,  pvro|)hosphate,  185 

Prof.  Flagg's,  182  '  Zone  of  Tomes,  117,  129 


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BARTHOLOW  i  ROBERTS ) .  CHOLERA  ;  ITS  CA  USA TION,  PREVENTION 
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BARTHOLOW  ROBERTS).  MEDICAL  ELECTRICITY.  A  PRACTICAL 
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AND^  SURGERY.  Third  edition.  In  one  octavo  volume  of  308  pages,  with  110  ilUis- 
trations. 

BELL    (F.  JEFFREY),     COMPARATIVE  ANATOMY  AND  PHYSIOLOGY. 

In  one  12mo.  volume  of  561  pages,  with  229  engravings.     Cloth,  $2.     See  Student^  Series 
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BELLAMY    (EDWARD).    A  MANUAL  OF  SURGICAL  ANAT03IY.    In  one 

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BERRY  ( GEORGE  A. ) .  DISEASES  OF  THE  EYE;  A  PRA CTICA L  TREA T- 
ISE  FOR  STUDENTS  OF  OPHTHALMOLOGY.  Second  edition.  Very  hand- 
some octavo  volume  of  745  pages,  with  197  original  illustrations  in  the  text,  of  which  87 
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BILLINGS  (JOHN  S.).  THE  NATIONAL  MEDICAL  DICTIONARY.  Includ- 
ing in  one  alphabet  English,  French,  German,  Italian  and  Latin  Technical  Terms  used  in 
Medicine  and  the  Collateral  Sciences.  In  two  very  handsome  imperial  octavo  volumes, 
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BLACK  (D.  CAMPBELL).  THE  URINE  IN  HEALTH  AND  DISEASE, 
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CALLY CONSIDERED.  In  one  12mo.  volume  of  256  pages,  with  73  engravings. 
Cloth,  $2.75. 

BLOXAM  (C.  L.).  CHEMISTRY,  INORGANIC  AND  ORGANIC.  With 
Experiments.  New  American  from  the  fifth  London  edition.  In  one  handsome  octavo 
volume  of  727  pages,  with  292  illustrations.     Cloth,  $2 ;  leather,  $3. 

BROADBENT  (W.  H.).  THE  PULSE.  In  one  12mo.  volume  of  317  pages,  with 
59  engravings.     Cloth,  $1.75.     See  Series  of  Clinical  Manuals,  page  13. 

BROWNE  ( LENNOX ) .     THE  THR OAT  AND  NOSE  AND  THEIR  DISEASES. 

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engravings  and  120  illustrations  in  color.     Cloth,  $6.50. 

KOCH'S   REMEDY   IN  RELATION   ESPECIALLY    TO    THROAT 

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whicli  are  colored,  and  17  charts.     Cloth,  $1.50. 

BRUCE    (J.    MITCHELL).     MATERIA    MEDIC  A    AND    THERAPEUTICS. 

Fifth  edition.     In  one  12mo.  volume  of  591  pages.     Cloth,  $1.50.     See  Student^  Series  oj 
Manuals,  page  14. 

BRUNTON  (T.  LAUDER).  A  MANUAL  OF  PHARMACOLOGY,  THERA- 
PEUTICS AND  MATERIA  MEDIC  A;  including  the  Pharmacy,  the  Physiological 
Action  and  the  Therapeutical  Uses  of  Drugs.     In  one  octavo  volume. 

BRYANT  (THOMAS).  THE  PRACTICE  OF  SURGERY.  Fourth  American 
from  the  fourth  English  edition.  In  one  imperial  octavo  volume  of  1040  pages,  with  727 
illustrations.     Cloth,  $6.50 ;  leather,  $7.50. 

BUMSTEAD  (F.  J.)  AND  TAYLOR  (R.  W.).  THE  PATHOLOGY  AND 
TREATMENT  OF  VENEREAL  DISEASES.  See  Taylor  on  Venereal  Diseases, 
page  15.     Just  ready. 

BURNETT  (CHARLES  H.).  THE  EAR:  ITS  ANAT03IY,  PHYSIOLOGY 
AND  DISEASES.  A  Practical  Treatise  for  the  Use  of  Students  and  Practitioners. 
Second  edition.  In  one  8vo.  volume  of  580  pages,  with  107  illustrations.  Cloth,  $4 ; 
leather,  $5. 

BUTLIN  (HENRY  T.).  DISEASES  OF  THE  TONGUE.  In  one  pocket-size 
12mo.  volume  of  456  pages,  with  8  colored  plates  and  3  engravings.     Limp  cloth,  $3.50. 

See  Series  of  Clinical  Manuals,  page  13. 

CARPENTER  (W.  B.).  PRIZE  ESSAY  ON  THE  USE  OF  ALCOHOLIC 
LIQUORS  IN  HEALTH  AND  DISEASE.  New  edition,  with  a  Preface  by  D.  F. 
CoNDiE,  M.D.     One  12mo.  volume  of  178  pages.     Cloth,  60  cents. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY.     In  one  large  octavo  volume. 


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CAETER  R.  BRUDENELL  AND  FROST  (W.  ADAMS).  OPHTHALMIC 
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one  plate.     Cloth,  $2.25.     See  Series  of  Clinical  Manuah,  page  13. 

CASPARI  CHARLES,  JR.).  A  TREATISE  ON  PHARMACY.  For  Students 
and  Pharmacist*.  In  one  handsome  octavo  volume  of  680  pages,  ^vith  288  illustrations. 
Cloth.  .*4.50. 

CHAMBERS  i  T.  K.  .  A  MASVAL  OF  DIET  IN  HEALTH  AND  DISEASE. 
In  one  handsome  8vo.  volume  of  302  pages.     Cloth,  $2.75. 

CHAPMAN  (HENRY  C. ).    A  TREATISE  ON  HUMAN  PHYSIOLOGY.    In 

one  octavo  volume  of  925  pages,  with  605  illustrations.     Cloth,  $5.50 ;  leather,  $6.50. 

CHARLES  T.  CRANSTOUNi.  THE  ELEMENTS  OF  PHYSIOLOGICAL 
AND  PATHOLOGICAL  CHEMISTRY.  In  one  handsome  octavo  volume  of  451 
pase-.  with  38  engravings  and  1  colored  plate.     Cloth,  $3.50. 

CHEYNE  (W.  WATSON).  THE  TREATMENT  OF  WOUNDS,  ULCERS 
AND  ABSCESSES.     In  one  12mo.  volume  of  207  pages.     Cloth,  $1.25. 

CHURCHILL  (FLEETWOOD).  ESSAYS  ON  THE  PUERPERAL  FEVER. 
In  one  octavo  volume  of  464  pages.     Cloth,  $2.50. 

CLARKE  (W.  B.j  AND  LOCKWOOD  (C.  B.).     THE  DISSECTOR'S  2IANUAL. 

In  one  12mo.  volume  of  396  pages,  with  49  engravings.     Cloth,  $1.50.     See  Siudenti^^  Series 
of  Manual?,  page  14. 

CLELAND  (JOHNi.  A  DIRECTORY  FOR  THE  DISSECTION  OF  THE 
HUMAN  B OD  Y.     In  one  12mo.  volume  of  178  pages.     Cloth,  $1.25. 

CLINICAL  MANUALS.     See  Series^  of  Clinical  Manuah,  page  13. 

CLOUSTON  THOMAS  S.).  CLINICAL  LECTURES  ON  MENTAL  DIS- 
EASES. Xew  (4th)  edition.  In  one  octavo  volume  of  740  pages,  with  15  plates.  Sliortlij. 
See  also  Folsom's  Abstract  of  Lau-s  of  U.  S.  on  Cu.-itody  of  Imane.  In  one  octavo  volume 
of  108  pages.     Cloth,  $1.50." 

CLOWES  I  FRANK).  ^^V  ELEMENTARY  TREATISE  ON  PRACTICAL 
CHEMISTRY  AND  QUALITATIVE  INORGANIC  ANALYSIS.  From  the 
fourth  English  edition.  In  one  handsome  12mo.  volume  of  387  pages,  with  55  engrav- 
ings.    Cloth,  $2.50. 

COATS  (JOSEPH).  A  TREATISE  ON  PATHOLOGY.  In  one  volume  of  829 
page-,  with  339  engravings.     Cloth,  $5.50 ;  leather,  $6.50. 

COLEMAN  (ALFRED).  A  MANUAL  OF  DENTAL  SURGERY  AND  PATH- 
OLOGY. ^^'ilh  Notes  and  Additions  to  adapt  it  to  American  Practice.  By  Thos.  C. 
Steixtvagex,  M.A.,  M.D.,  D.D.S.  In  one  handsome  octavo  volume  of  412  pages,  with 
331  engravings.     Cloth,  $3.25. 

CONDIE  (D.  FRANCIS'.  A  PRACTICAL  TREATISE  ON  THE  DISEASES 
OF  CHILDREN.  Sixth  edition,  revised  and  enlarged.  In  one  large  8vo.  volume  of 
719  pages.     Cloth,  .J5.25 ;  leather,  $6.25. 

CORNIL  (V.^.  SYPHILIS:  ITS  MORBID  ANATOMY,  DIAGNOSIS  AND 
THE  A  TMENT.  Translated,  with  Xotes  and  Additions,  by  J.  Hexky  C.  Sime^^,  M.D., 
and  J.  William  White,  M.L).  In  one  8vo.  volume  of  461  pages,  with  84  illastrations. 
Cloth,  $3.75. 

CULBRETH  (DAVID  M.  R.  > .    MA  TERIA  MEDIC  A  AND  PHARMACOL  0  G  Y. 

In  one  hand.'-ome  octavo  volume  of  812  pages,  with  445  engravings.     Cloth,  $4.75.     Jimt 

:'>  nd II, 

CULVER  ,E.  M.)  AND  HAYDEN  (J.  R.).  MANUAL  OF  VENEREAL  DIS- 
EASES.    In  one  12mo.  volume  of  289  pages,  with  33  engravings.     Cloth,  $1,75. 

DALTON  (JOHN  O.  A  TREATISE  ON  HUMAN  PHYSIOLOGY.  Seventh 
efiition,  thoroughly  revised  and  gieatly  improved.  In  one  very  handsome  octavo  volume 
of  722  pages,  with  252  engravings.     Cloth,  $5 ;  leather,  $6. 

DOCTRINES  OF  THE  CIRCULATION  OF  THE  BLOOD.  In  one  hand- 
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one  handsome  12mo.  volume  of  314  pages,  with  107  engravings.     Cloth,  $1.75. 

DAVIS  (F.H.).  LECTURES  ON  CLINICAL  MEDICINE.  •Second edition.  In 
one  12mo.  volume  of  287  pages.     Cloth,  $1.75. 

DAVIS  (EDWARD  P.).  A  TREATISE  ON  OBSTETRICS.  For  Students  and 
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and  .'!0  fuU-iiage  plates  in  colors  and  monochrome.     Cloth,  $5;  leather,  $6.    Just  ready. 

DE  LA  BECHE'S  GEOLOGICAL  OBSERVER.  In  one  large  octavo  volume  of  700 
pages,  with  300  engravings.     Cloth,  .'?4. 

DENNIS    (FREDERIC    S.)    AND    BILLINGS    (JOHN    S.).     A    SYSTEM  OF 

SURGERY.  In  Contributions  by  American  Authors.  In  four  very  handsome  octavo 
volumes,  containing  3(552  pages,  with  1585  engravings,  and  45  full-page  plates  in  colors 
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DERCUM  (FRANCIS  X.),  Editor.  A  TEXT-BOOK  ON  NERVOUS  DIS- 
EASES. By  American  Authors.  In  one  handsome  octavo  volume  of  1054  pages,  with 
341  engravings  and  7  colored  plates.     Cloth,  $6 ;  leather,  $7.     (Net.) 

DE  SCHWEINITZ  (GEORGE  E.^.  THE  TOXIC  AMBLYOPIAS ;  THEIR 
CLASSIFICATION,  HISTORY,  SYMPTOMS,  PATHOLOGY  AND  TREAT- 
MENT. Very  handsome  octavo,  240  pages,  46  engravings,  and  9  full-page  plates  in 
colors.     Limited  edition,  de  luxe  binding,  $4.     (Net.) 

DRAPER  'JOHN  C).  MEDICAL  PHYSICS.  A  Text-book  for  Students  and  Prac- 
titioners of  Medicine.  In  one  handsome  octavo  volume  of  734  pages,  with  376  engrav- 
ings.    Cloth,  .S4. 

DRUITT  (ROBERT).  THE  PRINCIPLES  AND  PRACTICE  OF  MODERN 
SURGERY.  A  new  American,  from  the  twelfth  London  edition,  edited  by  Staxley 
BovD,  F.R.C.S.  In  one  large  octavo  volume  of  965  pages,  with  373  engravings.  Cloth,  $4  ; 
leather,  $5. 

DUANE  (ALEXANDERS.  THE  STUDENT'S  DICTIONARY  OF  MEDICINE 
AND  THE  ALLIED  SCIENCES.  Comprising  the  Pronunciation,  Derivation  and 
Full  Explanation  of  Medical  Terms.  Together  with  much  Collateral  Descriptive  Matter, 
Numerous  Tables,  etc.  New  edition.  With  Appendix.  In  one  square  octavo  volume  of 
690  pages.  Cloth,  $3;  half  leather,  $3.25;  full  sheep,  $3.75.  Thumb-letter  Index  for 
quick  use,  50  cents  extra.     Just  ready. 

DUNCAN  (J.  MATTHEWS).  CLINICAL  LECTURES  ON  THE  DISEASES 
OF  W03IEN.  Delivered  in  St.  Bartholomew's  Hospital.  In  one  octavo  volume  of 
175  pages.     Cloth,  $1.50. 

DUNGLISON  (ROBLEY).  A  DICTIONARY  OF  MEDICAL  SCIENCE.  Con- 
taining a  full  Explanation  of  the  Various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Medical  Chemistry,  Pharmacy,  Pharmacology,  Therapeutics,  Medicine,  Hygiene,  Dietetics, 
Pathology,  Surgery,  Ophthalmology,  Otology,  Laryngology,  Dermatology,  Gynecology, 
Obstetrics,  Pediatrics,  Medical  Jurisprudence,  Dentistry,  etc.,  etc.  By  Robley  Dungli- 
sox,  M.D.,  LL.D.,  late  Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  Col- 
lege of  Philadelphia.  Edited  by  Richard  J.  Duxglisox,  A.M.,  M.D.  Twenty-first 
edition,  thoroughly  revised  and  greatly  enlarged  and  improved,  with  the  Pronunciation, 
Accentuation  and  Derivation  of  the  Terms.  "With  Appendix.  In  one  magnificent 
imperial  octavo  volume  of  1225  pages.  Cloth,  $7  ;  leather,  $8.  Thumb-letter  Index  for 
quick  use,  75  cents  extra.     Just  ready. 

EDES  (ROBERT  T.\  TEXT-BOOK  OF  THERAPEUTICS  AND  MATERIA 
MEDIC  A.     In  one  8vo.  volume  of  544  pages.     Cloth,  $3.50;  leather,  $4.50. 

EDIS  (ARTHUR  W.).  DISEASES  OF  WOMEN.  A  Manual  for  Students  and 
Practitioners.  In  one  handsome  8vo.  volume  of  576  pages,  with  148  engravings. 
Cloth,  $3 ;  leather,  $4. 

ELLIS  (GEORGE  VINERY.  DEMONSTRATIONS  IN  ANATOMY.  Being  a 
Guide  to  the  Knowledge  of  the  Human  Body  by  Dissection.  From  the  eighth  and  revised 
English  edition.  In  one  octavo  volume  of  716  pages,  with  249  engravings.  Cloth.  $4.25 ; 
leather,  $5.25. 

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EMMET    (THOMAS   ADDIS).     THE  PRINCIPLES  AND   PRACTICE    OF 

G  YN^ECOLOGY.  For  the  ase  of  Students  and  Practitioners.  Third  edition,  enlarged 
and  revised.  In  one  large  8vo.  volume  of  880  pages,  with  150  original  engravings. 
Clotli,  .$5  ;  leather,  §6. 

ERICHSEN  (JOHN  E.).  THE  SCIENCE  AND  ART  OF  SURGERY.  A  new 
-^jnerican  from  the  eighth  enlarged  and  revised  London  edition.  In  two  large  octavo 
volumes  containing  2.316  pages,  with  984  engravings.     Cloth,  $9  ;  leather,  $11. 

ESSIG  (CHARLES  J.).  PROSTHETIC  DENTISTRY.  See  American  Text-books 
of  Dentistry,  page  2. 

FARQUHARSON  (ROBERT).  A  GUIDE  TO  THERAPEUTICS.  Fourth 
American  from  fourth  English  edition,  revised  bv  Fra^tk  Woodbttey,  M.D.  In  one 
12mo.  volume  of  581  pages.     Cloth,  §2.50. 

FIELD  (GEORGE  P.).  A  MANUAL  OF  DISEASES  OF  THE  EAR.  Fourth 
edition.  In  one  octavo  volume  of  391  pages,  vAth.  73  engravings  and  21  colored  plates. 
Cloth,  .?.3.75. 

FLINT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND  PRACTICE 
OF  MEDICINE.  New  (7th)  edition,  thoroughly  revised  by  Fbedebick  P.  Henry, 
M.D.     In  one  large  8vo.  volume  of  1143  pages,  with  engravings.     Cloth,  $5;  leather,  $6. 

A  MANUAL  OF  AUSCULTATION  AND  PERCUSSION ;  of  the  Physi- 


cal Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.  Fifth 
edition,  revised  by  James  C.  Wilson,  M.D.  In  one  handsome  12mo.  volume  of  274 
pages,  with  12  engravings. 

A   PRACTICAL    TREATISE   ON   THE  DIAGNOSIS  AND    TREAT- 


MENT OF  DISEASES  OF   THE   HEART.     Second  edition,  enlarged.     In  one 
octavo  volume  of  550  pages.     Cloth,  $4. 

A   PRACTICAL   TREATISE  ON  THE  PHYSICAL  EXPLORATION 


OF  THE  CHEST,  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING 
THE  RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  octavo  vol- 
ume of  591  pages.     Cloth,  $4.50. 

MEDICAL  ESSA  YS.     In  one  12mo.  volume  of  210  pages.     Cloth,  $1.38. 

ON  PHTHISIS :  ITS  MORBID  ANA  TO  MY,  ETIOL  OGY,  ETC.    A  Series 


of  Clinical  Lectures.     In  one  8vo.  volume  of  442  pages.     Cloth,  $3.50. 

FOLSOM  (C.  F.).  ^^V  ABSTRACT  OF  STATUTES  OF  U  S.  ON  CUSTODY 
OF  THE  INSANE.     In  one  8vo.  volume  of  108  pages.     Cloth,  $1.50. 

FORMULARY,  THE  NATIONAL.  See  StilU,  Makch  &  Caspari's  National  Dispensa- 
forif,  page  14. 

FOSTER  (MICHAELj.  A  TEXT-BOOK  OF  PHYSIOLOGY.  New  (6th)  and 
revised  American  from  the  sixth  English  edition.  In  one  large  octavo  volume  of  923 
pages,  with  257  illustrations.     Cloth,  $4.50 ;  leather,  $5.50. 

FOTHERGILL  (J.  MILNER).  THE  PRACTITIONER'S  HAND-BOOK  OF 
TREATMENT.  Third  edition.  In  one  handsome  octavo  volume  of  664  pages. 
Cloth,  $3.75 ;  leather,  $4.75. 

FOWNES  'GEORGE).  A  MANUAL  OF  ELEMENTARY  CHEMISTRY  {IN- 
ORGANIC AND  ORGANIC).  Twelfth  edition.  Embodying  Watts'  PAj/sim^  aTid 
Inorr/anir:  C/iemiatry.  In  one  royal  12mo.  volume  of  1061  pages,  with  168  engravings,  and 
1  colored  plate.     Cloth,  $2.75 ;  leather,  $3.25. 

FRANKLAND  (E.)  AND  JAPP  (F.  R.).  INORGANIC  CHEMISTRY.  In  one 
handsome  octavo  volume  of  677  pages,  with  51  engravings  and  2  plates.  Cloth,  $3.75; 
leather,  $4.75. 

FULLER  (EUGENE).  DISORDERS  OF  THE  SEXUAL  ORGANS  IN  THE 
MALE.  In  one  very  handsome  octavo  volume  of  238  pages,  with  25  engravings  and 
8  full-page  plates.     Cloth,  $2.     Just  ready. 

FULLER  f HENRY).  ON  DISEASES  OF  THE  L  UNGS  AND  AIR-PASSAGES. 
Their  Pathology,  Physical  Diagnosis,  Symptoms  and  Treatment.  From  second  English 
edition.     In  one  8vo.  volume  of  475  pages.     Cloth,  $3.50. 


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GANT  (FREDERICK  JAMES).  THE  STUDENT'S  SURGERY.  A  Multum  in 
I'iirvo.     In  one  s([iiare  octavo  volume  of  845  pages,  \vith  159  engravings.     Cloth,  $3.75. 

GIBBES  (HENEAGE).  PRACTICAL  PATHOLOGY  AND  MORBID  HIS- 
TOLOGY. In  one  very  handsome  octavo  volume  of  314  pages,  with  60  illastrations, 
mostly  photographic.     Cloth,  .?2.75. 

GIBNEY  (V.  P.).     ORTHOPEDIC  SURGERY.     For  the  use  of  Practitioners  and 

Students.     In  one  8vo.  volume  profusely  illastrated.     Preparing. 

GOULD  (A.  PEARCE).  SURGICAL  DIAGNOSIS.  In  one  12mo.  volume  of  589 
pages.     Cloth,  $2.     See  Students'  Series  of  Manuals,  page  14. 

GRAY    (HENRY).    ANATOMY,   DESCRIPTIVE  AND   SURGICAL.     A  new 

American  edition,  thoroughly  revised.  In  one  imperial  octavo  volume  of  1239  pages, 
with  772  large  and  elaborate  engravings.  Price  with  illustrations  in  colors,  cloth,  $7 ; 
leather,  $8.     Price,  with  illustrations  in  black,  cloth,  $6 ;  leather,  %1.     Just  ready. 

GRAY  (LANDON  CARTER).  A  TREATISE  ON  NERVOUS  AND  MENTAL 
DISEASES.  Vov  Students  and  Practitioners  of  Medicine.  New  (2d)  edition.  In  one 
handsome  octavo  volume  of  728  pages,  with  172  engravings  and  3  colored  plates.  Cloth, 
$4.75;  leather,  85  75.     Just  ready. 

GREEN  (T.  HENRY).  AN  INTRODUCTION  TO  PATHOLOGY  AND  MOR- 
BID ANATOMY.  New  (7th)  American  from  the  eighth  London  edition.  In  one 
handsome  octavo  volume  of  595  pages,  with  224  engravings  and  a  colored  plate.     Cloth, 

$2.75. 

GREENE  (WILLIAM  H.).    A  MANUAL  OF  MEDICAL  CHEMISTRY.    For 

the  Use  of  Students.  Based  upon  Bowmaj^j's  Medical  Chemistry.  In  one  12mo.  volume 
of  310  pages,  with  74  illustrations.     Cloth,  $1.75. 

GROSS  (SAMUEL  D.).  A  PRACTICAL  TREATISE  ON  THE  DISEASES, 
INJURIES  AND  MALFORMATIONS  OF  THE  URINARY  BLADDER, 
THE  PROSTATE  GLAND  AND  THE  URETHRA.  Third  edition,  thoroughly 
revised  and  edited  by  Samuel  W.  Gross,  M.  D.  In  one  octavo  volume  of  574  pages, 
with  170  illustrations.     Cloth,  §4.50. 

HABERSHON  (S.  0.).  ON  THE  DISEASES  OF  THE  ABDOMEN,  comprising 
those  of  the  Stomach,  CEsophagus,  Csecum,  Intestines  and  Peritoneum.  Second  Amer- 
ican from  the  third  English  edition.  In  one  octavo  volume  of  554  page**,  with  11  engrav- 
ings.    Cloth,  $3.50. 

HAMILTON  (ALLAN  McLANE ) .  NER  VO  US  DISEASES,  THEIR  DESCRIP- 
TION AND  TREATMENT.  Second  and  revised  edition.  In  one  octavo  volume  of 
598  pages,  with  72  engravings.     Cloth,  $4. 

HAMILTON  (FRANK  H.).    A   PRACTICAL   TREATISE  ON  FRACTURES 

AND  DISLOCATIONS.  Eighth  edition,  revised  and  edited  by  Stephen  Smith, 
A.M.,  M.D.  In  one  handsome  octavo  volume  of  832  pages,  with  507  engravings. 
Cloth,  $5.50;  leather,  $6.50. 

HARDAWAY  iW.  A.).  MANUAL  OF  SKIN  DISEASES.  In  one  12mo.  volume 
of  440  pages.     Cloth,  $3. 

HARE    (HOB ART   AMORY).    A    TEXT-BOOK   OF   PRACTICAL    THERA- 

PE  UTICS,  with  Special  Keference  to  the  Application  of  Eemedial  Measures  to  Disease 
and  their  Employment  upon  a  Rational  Basis.  With  articles  on  various  subjects  by  well- 
known  specialists.  New  (5th)  and  revised  edition.  In  one  octavo  volume  of  740  pages. 
Cloth,  $3.75;  leather,  $4.75.     Just  ready. 

PRACTICAL  DIAGNOSIS.     The  Use  of  Symptoms  in  the  Diagnosis  of  Disease. 

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and  monochrome.     Cloth,  $4.75.     Just  rmdy. 

HARE  (HOBART  AMORY),  Editor.  A  SYSTEM  OF  PRACTICAL  THERA- 
PEUTICS. By  American  and  Foreign  Authors.  In  a  series  of  contributions  by  emi- 
nent practitioners.  In  four  large  octavo  volumes  comprising  about  4500  pages,  with  about 
550  engravings.  Vol.  IV.,  in  press.  Price  per  volume,  cloth,  $5 ;  leather,  $6  ;  half  Russia, 
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HARTSHORNE    (HENRY).     ESSENTIALS    OF    THE   PRINCIPLES  AND 

PRACTICE    OF  MEDICINE.    Fifth  edition.     In  one  12mo.  volume,  669  pages, 
with  144  engravings.     Cloth,  82. 75 ;  half  bound,  .?3. 

A   HANDBOOK  OF  ANATOMY  AND   PHYSIOLOGY.     In  one  12mo. 


volume  of  310  pages,  mth  220  engravings.     Cloth,  §1.75. 

A  CONSPECTUS  OF  THE  MEDICAL  SCIENCES.     Comprising  Manuals 


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trations.    Cloth,  84. 25 ;  leather,  85. 

HAYDEN  I  JAMES  R.).     A  MANUAL  OF  VENEREAL  DISEASES.     In  one 

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HAYEM  (GEORGES)  AND  HARE  (H.  A.).  PHYSICAL  AND  NATURAL 
THERAPEUTICS.  The  Kemedial  Use  of  Heat,  Electricity,  Modifications  of  Atmos- 
pheric Pressure,  Climates  and  jNIineral  Waters.  Edited  by  Prof.  H.  A.  Haee,  M.D. 
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HERMAN    (G.    ERNEST).     FIRST  LINES   IN  MIDWIFERY.     In  one  12mo. 

volume  of  198  pages,  with  80  engravings.  Cloth,  $1.25.  See  Student^  Series  of  Manuals, 
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HERMANN  (L.).  EXPERIMENTAL  PHARMACOLOGY.  A  Handbook  of  the 
Methods  for  Determining  the  Physiological  Actions  of  Drugs.  Translated  by  Egbert 
Meade  Smith,  M.D.     In  one  12mo.  vol.  of  199  pages,  with  32  engravings.     Cloth,  $1.50. 

HERRICK  (JAMES  B.).  A  HANDBOOK  OF  DIAGNOSIS.  In  one  handsome 
12mo.   volume  of  429  pages,  with  80  engi-avings  and  2  colored  plates.     Cloth,  82.50. 

HILL  (BERKELEY).    SYPHILIS  AND  LOCAL  CONTAGIO  US  DISORDERS. 

In  one  8vo.  volume  of  479  pages.     Cloth,  $3.25. 

HILLIER  (THOMAS).  A  HANDBOOK  OF  SKIN  DISEASES.  Second  edition. 
In  one  royal  12mo.  volume  of  353  pages,  with  two  plates.     Cloth,  $2.25. 

HIRST  (BARTON  C.)  AND  PIERSOL  (GEORGE  A.).  HUMAN  MONSTROS- 
ITIES. Magnificent  folio,  containing  220  pages  of  text  and  illustrated  with  123  engrav- 
ings and  39  large  photographic  plates  from  nature.  In  four  parts,  price  each,  $5.  Limited 
edition.     For  sale  by  subscription  only. 

HOBLYN  fRICHARD  D.).  A  DICTIONARY  OF  THE  TERMS  USED  IN 
MEDICINE  AND  THE  COLLATERAL  SCIENCES.  In  one  12mo.  volume  of 
520  double-columned  pages.     Cloth,  81.50;  leather,  $2. 

HODGE  (HUGH  L.).  ON  DISEASES  PECULIAR  TO  WOMEN,  INCLUDING 
DISPLACEMENTS   OF   THE    UTERUS.     Second  and  revised  edition.     In  one 

yvo.  volume  of  519  pages,  with  illustrations.     Cloth,  $4.50. 

HOFFMANN  (FREDERICK)  AND  POWER  (FREDERICK  B.).  A  MANUAL 
OF  CHEMICAL  ANALYSIS,  as  Applied  to  the  Examination  of  Medicinal  Chemicals 
and  their  Preparations.  Third  edition,  entirely  rewritten  and  much  enlarged.  In  one 
handsome  octavo  volume  of  621  pages,  with  179  engravings.     Cloth,  $4.25. 

HOLDEN  (LUTHER).  LANDMARKS,  MEDICAL  AND  SURGICAL.  From 
the  third  English  edition.  With  additions  by  W.  W.  Keen,  M.D.  In  one  royal  12mo. 
volume  of  148  pages.     Cloth,  81. 

HOLMES  (TIMOTHY).  A  TREATISE  ON  SURGERY.  Its  Principles  and 
Practice.  A  new  American  from  the  fifth  English  edition.  Edited  by  T.  Pickering 
Pick,  F.R.C.S.  In  one  handsome  octavo  volume  of  1008  pages,  with  428  engravings. 
Cloth,  $6  ;  leather,  $7. 

A  SYSTEM  OF  SURGERY.     With  notes  and  additions  by  various  American 


With  n 
authors.     Edited  by  John  H.  Packard,  M^D.     In  three  very  handsome  8vo.  volumes 
containing  3137  double-columned  pages,  with  979  engravings  and  13  lithographic  plates. 
Per  volume,  cloth,  $6  ;  leather,  87  ;  half  Russia,  87.50.     For  sale  by  subscription  only. 

HORNER  '  WILLIAM  E . ) .  SPEC  I  A  L  A  NA  TOM  Y  A  ND  HISTOL  0  G  Y.  Eighth 
<  dition,  rfviscfl  and  modified.  In  two  large  8vo.  volumes  of  1007  pages,  containing  320 
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HUDSON  (A.).  LECTURES  ON  THE  STUDY  OF  FEVER.  In  one  octavo 
volume  of  308  pages.     Cloth,  $2.50. 

HUTCHINSON  (JONATHAN).  SYPHILIS.  In  one  pocket-size  12mo.  volume  of 
542  pages,  with  8  chromo-lithographic  plates.  Cloth,  $2.25.  See  Series  of  Clinical  Man- 
ual.'^, page  13. 

HYDE  (JAMES  NEVINS).  A  PRACTICAL  TREATISE  ON  DISEASES  OF 
'THE  SKIK.  New  (4th )  edition,  thoroughly  revised.  In  one  octavo  volume  of  808  pages, 
with  1 10  engravings  and  12  full-page  plates,  4  of  which  are  colored.     Shortly. 

JACKSON  (GEORGE  THOMAS).     THE  READY-REFERENCE  HANDBOOK 

OF  DISEASES  OF  THE  SKIN.     New  (2d)  edition.     In  one  12mo.  volume  of  589 
pages,  with  69  engravings,  and  one  colored  plate.     Cloth,  $2.75.     Just  ready. 

JAMIESON  (W.  ALLAN).  DISEASES  OF  THE  SKIN.  Third  edition.  In  one 
octavo  volume  of  656  pages,  with  1  engraving  and  9  double-page  chromo-lithographic 
plates.     Cloth,  §6. 

JONES  (C.  HANDFIELD).  CLINICAL  OBSERVATIONS  ON  FUNCTIONAL 
NER  VO  US  DISORDERS.  Second  American  edition.  In  one  octavo  volume  of  340 
pages.     Cloth,  $3.25. 

JULER  (HENRY).  A  HANDBOOK  OF  OPHTHALMIC  SCIENCE  AND 
PR  A  CTICE.  Second  edition.  In  one  octavo  volmne  of  549  pages,  with  201  engrav- 
ings, 17  chromo-lithographic  plates,  test-tvpes  of  Jaeger  and  Snellen,  and  Holmgren's 
Color-Blindness  Test.     Cloth,  $5.50;  leather,  $6.50. 

KIRK  (EDWARD  C).  OPERATIVE  DENTISTRY.  See  American  Text-books  oj 
Dentistry,  page  2. 

KING  (A.  F.  A.).  A  MANUAL  OF  OBSTETRICS.  Sixth  edition.  In  one  12mo. 
volume  of  532  pages,  with  221  illustrations.     Cloth,  $2.50. 

KLEIN  (E.).  ELEMENTS  OF  HISTOLOGY.  Fourth  edition.  In  one  pocket-size 
12mo.  volume  of  376  pages,  with  194  engravings.  Cloth,  $1.75.  See  Student^  Series  of 
Manuah,  page  14. 

LANDIS  (HENRY  G.).  THE  MANAGEMENT  OF  LABOR.  In  one  handsome 
12mo.  volume  of  329  pages,  with  28  illustrations.     Cloth,  $1.75. 

LA  ROCHE  (R.).  YELLOW  FEVER.  In  two  Svo.  volumes  of  1468  pages. 
Cloth,  $7. 

PNEUMONIA.     In  one  Svo.  volume  of  490  pages.     Cloth,  $3. 

LAURENCE  (J.  Z.)  AND  MOON  (ROBERT  C).  A  HANDY-BOOK  OF 
OPHTHALMIC  SURGERY.  Second  edition.  In  one  octavo  volume  of  227  pages, 
with  66  engravings.     Cloth,  $2.75. 

LAWSON  (GEORGE).    INJURIES  OF  THE  EYE,  ORBIT  AND  EYELIDS. 

From  the  last  English  edition.     In  one  handsome  octavo  volume  of  404  pages,  with  92 
engravings.     ( 'loth,  $3.50. 

LEA  (HENRY  C).  CHAPTERS  FROM  THE  RELIGIOUS  HISTORY  OF 
SPAIN;  CENSORSHIP  OF  THE  PRESS;  MYSTICS  AND  ILLUMINATI ; 
THE  ENDEMONIADAS ;  EL  SANTO  NINO  DE  LA  GUARDIA;  BRI- 
ANDA  DE  BARDAXI.     In  one  12mo.  volume  of  522  pages.     Cloth,  $2.50. 

A  HISTORY  OF  AURICULAR  CONFESSION  AND  INDULGENCES 


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Per  volume,  cloth,  $3.     Complete  work  just  ready. 

FORMULARY  OF  THE  PAPAL  PENITENTIARY.     In  one  octavo  vol- 


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SUPERSTITION  AND  FORCE;  ESSAYS  ON  THE  WAGER  OF  LAW, 


THE  WAGER  OF  BATTLE,  THE  ORDEAL  AND  TORTURE.  Fourth 
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LEA  (HENRY  C).  STUDIES  IN  CHURCH  HISTORY.  The  Rise  of  the  Tem- 
poral Power — Benefit  of  Clergy — Excommunication.  New  edition.  In  one  handsome 
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AN  HISTORICAL  SKETCH  OF  SACERDOTAL  CELIBACY  IN  THE 


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pages.     Cloth,  $4.50, 

LEE  (HENRYj   ON  SYPHILIS.     In  one  8vo.  volume  of  246  pages.     Cloth,  |2.2o. 

LEHMANN  (C.  G.).  A  MANUAL  OF  CHEMICAL  PHYSIOLOGY.  In  one 
Svo.  volume  of  327  pages,  with  41  engravings.     Cloth,  $2.25. 

LEISHMAN  (WILLIAM).  A  SYSTE3I  OF  MIDWIFERY.  Including  the  Dis- 
eases of  Pregnancy  and  the  Puerperal  State.     Fourth  edition.     In  one  octavo  volume. 

LOOMIS  (ALFRED  L.)  AND  THOMPSON  (W.  OILMAN),  Editors.  A  SYS- 
TEM OF  PR  A  CTICAL  MEDICINE.  In  Contributions  by  Various  American  Authors. 
In  four  very  handsome  octavo  volumes  of  about  900  pages  each,  fully  illustrated  in  black 
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only.     Full  prospectus  free  on  application  to  the  Publishers. 

LUDLOW  (J.  L.l.  A  MANUAL  OF  EXAMINATIONS  UPON  ANATOMY, 
PHYSIOLOGY,  SURGERY,  PRACTICE  OF  MEDICINE,  OBSTETRICS, 
MATERIA  MEDIC  A,  CHEMISTRY,  PHARMACY  AND  THERAPEUTICS. 
To  which  is  added  a  Medical  Formulary.  Third  edition.  In  one  ro3'al  12mo.  volume 
of  816  pages,  with  370  engravings.     Cloth,  $3.25;  leather,  $3.75. 

LUFF  (ARTHUR  P.).  MANUAL  OF  CHEMISTRY,  for  the  use  of  Students  of 
Medicine.  In  one  12mo.  volume  of  522  pages,  with  36  engravings.  Cloth,  $2.  See 
Student.^  Series  of  Manuals,  page  14. 

LYMAN  (HENRY  M.).  THE  PRACTICE  OF  MEDICINE.  In  one  very  hand- 
some octavo  volume  of  925  pages  with  170  engravings.     Cloth,  $4.75;  leather,  $5.75. 

LYONS  (ROBERT  D.).  A  TREATISE  ON  FEVER.  In  one  octavo  volume  of  362 
pages.     Cloth,  $2.25. 

MACKENZIE  (JOHN  NOLAND).  THE  DISEASES  OF  THE  NOSE  AND 
THROAT.  In  one  handsome  octavo  volume  of  about  600  pages,  richly  illustrated. 
Preparing, 

MAISCH  (JOHN  M.).  A  MANUAL  OF  ORGANIC  MATERIA  MEDICA. 
New  (6th j  edition,  thoroughly  revised  by  H.  C.  C.  Maisch.  Ph.G.,  Ph.D.  In  one  very 
handsome  12mo.  volume  of  509  pages,  with  285  engravings.     Cloth,  $3. 

MANUALS.  See  Student.^  Quiz  Series,  page  14,  Students'  Series  of  Manmds,  page  14,  and 
Series  of  Clinical  Manuals,  page  13. 

MARSH  (HOWARD),  DISEASES  OF  THE  JOINTS.  In  one  12mo.  volume  of 
468  pages,  with  64  engravings  and  a  colored  plate.  Cloth,  $2.  See  Series  of  Clinical 
Maniuds,  page  13. 

MAY  (C.  H.).  MANUAL  OF  THE  DISEASES  OF  WOMEN.  For  the  use  of 
Students  and  Practitioners.  Second  edition,  revised  by  L.  S.  Rau,  M.D.  In  one  12mo. 
volume  of  360  pages,  with  31  engravings.     Cloth,  $1.75. 

MITCHELL  (JOHN  K.).  REMOTE  CONSEQUENCES  OF  INJURIES  OF 
NERVES  AND  TIIEIR[TREATMENT.  In  one  handsome  12mo.  volume  of  239 
page^,  with  12  illustrations.     Cloth  $1.75.     Jiist  ready. 

MORRIS  (HENRY).  SURGICAL  DISEASES  OF  THE  KIDNEY.  In  one 
12mo.  volume  of  554  pages,  with  40  engravings  and  6  colored  plates.  Cloth,  $2.25.  See 
Series  of  Clinicfd  Mammls,  page  13. 


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MORRIS  (MALCOLM).  DISEASES  OF  THE  SKIN.  In  one  square  8vo.  volume 
of  ")7:i  pages,  with  19  chromo-lithographic  figures  and  17  engravings.     Cloth,  $3.50. 

MULLER  (J.).  PRINCIPLES  OF  PHYSICS  AND  METEOROLOGY.  In  one 
largf  8vo.  volume  of  023  pages,  with  538  engravings.     Cloth,  $4.50. 

MUSSER  (JOHN  H.).  A  PRACTICAL  TREATISE  ON  MEDICAL  DIAG- 
NOSIS, for  Students  and  Physicians.  New  (2d)  edition.  In  one  octavo  volume  of 
931  pages,  illustrated  with  177  engravings  and  11  full-page  colored  plates.     Cloth,  $5  ; 

leatiier,  i^G.     Just  ready. 

NATIONAL  DISPENSATORY.     See  Stille,  Maisch  &  Caspari,  page  14. 

NATIONAL    FORMULARY.      See  Stille,  Maisch  &  Caspari's  National  Dispensatory, 

page  14. 

NATIONAL  MEDICAL  DICTIONARY.     See  BilUngs,  page  3. 

NETTLESHIP  (E.).  DISEASES  OF  THE  EYE.  Fourth  American  from  fifth 
English  edition.  In  one  12mo.  volume  of  504  pages,  with  164  engravings,  test-types  and 
formulae  and  color-blindness  test.     Cloth,  $2. 

NORRIS  (WM.  F.)  AND  OLIVER  (CHAS.  A.).  TEXT-BOOK  OF  OPHTHAL- 
MOLOGY. In  one  octavo  volume  of  641  pages,  with  357  engravings  and  5  colored 
plates.     Cloth,  $5  ;  leather,  §6. 

OWEN  (EDMUND).  SURGICAL  DISEASES  OF  CHILDREN.  In  one  12mo. 
volume  of  525  pages,  with  85  engravings  and  4  colored  plates.  Cloth,  $2.  See  Series  oj 
Clinical  Manruils,  page  13. 

PARK  (ROSWELL),  Editor.  A  TREATISE  ON  SURGERY,  by  .\merican  Authors. 
For  Students  and  Practitioners  of  Surgery  and  Medicine.  In  two  magnificent  octavo 
volumes,  ^'ol.  1.,  General  Surgery,  799  pages,  with  356  engravings  and  21  full-page  plates 
in  colors  and  monochrome.  Vol.  11.,  Special  Surgei-y,  796  pages,  with  451  engravings 
and  17  full-page  plates  in  colors  and  monochrome.  Complete  work  jitst  ready.  Price  per 
volume,  cloth,  $4.50;  leather,  $5.50.     Net. 

PARRY  (JOHN  S.).  EXTRA-UTERINE  PREGNANCY,  ITS  CLINICAL 
HISTORY,  DIAGNOSIS,  PROGNOSIS  AND  TREATMENT.  In  one  octavo 
volume  of  272  pages.     Cloth,  $2.50. 

PARVIN  (THEOPHILUS).  THE  SCIENCE  AND  ART  OF  OBSTETRICS. 
Third  edition  In  one  handsome  octavo  volume  of  677  pages,  with  267  engravings  and 
2  colored  plates,     (loth,  $4.25  ;  leather,  $5  25. 

PAVY  (F.  W.).  A  TREATISE  ON  THE  FUNCTION  OF  DIGESTION,  ITS 
DISORDERS  AND  THEIR  TREATMENT  From  the  second  London  edition. 
In  one  8vo.  volume  of  238  pages.     Cloth,  $2. 

PAYNE   (JOSEPH  FRANK).    A   MANUAL  OF  GENERAL  PATHOLOGY. 

Designed  as  an  Introduction  to  the  Practice  of  Medicine.     In  one  octavo  volume  of  524 
pages,  with  153  engravings  and  1  colored  plate.     Cloth,  $3.50. 

PEPPER'S  SYSTEM  OF  MEDICINE.    See  page  2. 

PEPPER  (A.  J;).  SURGICAL  PATHOLOGY.  In  one  12mo  volume  of  511  pages, 
with  81  engravings.     Cloth,  $2.     See  Student^  Series  of  Manuals,  page  14. 

PICK  (T.  PICKERING).  FRACTURES  AND  DISLOCATIONS.  In  one  12mo. 
volume  of  530  pages,  with  93  engravings.    Cloth.  $2.    See  Series  of  Clinical  Manuak,  p.  13. 

PIRRIE  (WILLIAM) .  THE  PRINCIPLES  AND  PRA CTICE  OF  SURGER  Y. 
In  one  octavo  volume  of  780  pages,  with  316  engravings.     Cloth,  $3.75. 

PLAYFAIR  (W.  S.).  A  TREATISE  ON  THE  SCIENCE  AND  PRACTICE 
OF  MID  WIFER  Y.  Sixth  American  from  the  eighth  English  edition.  Edited,  with 
additions,  by  R.  P.  Harris,  M.D.  In  one  octavo  volume  of  697  pages,  with  217  engrav- 
ings and  5  plates.     Cloth,  $4 ;  leather,  $5. 

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POLITZER  fADAM).  A  TEXT-BOOK  OF  THE  DISEASES  OF  THE  EAR 
AND  ADJACENT  ORGANS.  Second  American  from  the  third  German  edition. 
Translated  by  Oscar  Dodd,  M.I) ,  and  edited  by  Sir  William  Dalby,  F.E.C.S.  In 
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POWER  (HENRY).  HUMAN  PHYSIOLOGY.  Second  edition.  In  one  12mo. 
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PURDY  (CHARLES  W.).  BRIGHT'S  DISEASE  AND  ALLIED  AFFEC- 
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ings.    Cloth,  $2 

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QUIZ  SERIES.     See  Students'  Quiz  Series,  page  14. 

RALFE  (CHARLES  H.).  CLINICAL  CHEMISTRY.  In  one  12mo.  volume  of 
314  pages,  with  16  engravings.     Cloth,  §1.50.     See  Student^  Series  of  Manuals,  page  14. 

RAMSBOTHAM  (FRANCIS  H.).     THE  PRINCIPLES  AND  PRACTICE  OF 

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640  pages,  with  64  plates  and  numerous  engravings  in  the  text.  Strongly  bound  in 
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REICHERT  (EDWARD  T.).  A  TEXT-BOOK  ON  PHYSIOLOGY.  In  one 
handsome  octavo  volume  of  about  800  pages,  richly  illustrated.     Preparing. 

REMSEN    (IRA).     THE  PRINCIPLES  OF  THEORETICAL    CHEMISTRY. 

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RICHARDSON   (BENJAMIN  WARD).    PREVENTIVE  MEDICINE.    In  one 

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ROBERTS  (JOHN  B.).  THE  PRINCIPLES  AND  PRACTICE  OF  MODERN 
SURGERY.  In  one  octavo  volume  of  780  pages,  with  501  engravings.  Cloth,  $4.50; 
leather,  $5.50. 

THE  COMPEND  OF  ANATOMY.     For  use  in  the  Dissecting  Room  and  in 

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ROBERTS  (SIR  WILLIAM).  A  PRACTICAL  TREATISE  ON  URINARY 
AND  RENAL  DISEASES,  INCLUDING  URINARY  DEPOSITS.  Fourth 
American  from  the  fourth  London  edition.  In  one  very  handsome  8vo.  volume  of  609 
pages,  with  81  illustrations.     Cloth,  $3.50. 

ROBERTSON  (3.  McGREGOR).     PHYSIOLOGICAL  PHYSICS.     In  one  12mo. 

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$4.50:  leather,  $5.50. 

SAVAGE  'GEORGE  H.).  INSANITY  AND  ALLIED  NEUROSES,  PRACTI- 
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ings.    Cloth,  $2.     See  Series  of  Clinical  Manuah,  page  13. 

SCHAFER  (EDWARD  A.).  THE  ESSENTIALS  OF  HISTOLOGY,  DESCRIP- 
TIVE AND  PRACTICAL.  For  the  use  of  Students.  New  (4th)  edition.  In  one 
iiand'^ome  octavo  volume  of  311  pages,  with  288  illustrations.    'Cloth,  $3. 

Philadelphia,  706,  708  and  710  Sansom  St.— New  York,  111  Fifth  Ave.  {cor.  18th  St.). 


LEA     BROTHERS    &     CO.S    PUBLICATIONS.  13 

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Tli  j)r<'sx. 

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SIMON  (W.).  MANUAL  OF  CHEMISTRY.  A  Guide  to  Lectures  and  Laboratory 
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SMITH  (J.  LEWIS).  A  TREATISE  ON  THE  DISEASES  OF  INFANCY 
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SOLLY  (S.  EDWIN).  A  HANDBOOK  OF  MEDICAL  CLIMATOLOGY, 
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STILLE  (ALFRED).  CHOLERA;  ITS  ORIGIN,  HISTORY,  CAUSATION, 
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14  LEA    BROTHERS    &     CO.' S    PUBLICATIONS. 


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T AIT  ( L AWSON ) .  DISEASES  OF  WOMEN  AND  ABD  OMINAL  S UR  GER  Y. 
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TAYLOR  (ROBERT  W.).  THE  PATHOLOGY  AND  TREATMENT  OF 
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A    CLINICAL    ATLAS    OF    VENEREAL    AND    SKIN    DISEASES. 


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SEXUAL  DISORDERS  IN  THE   MALE  AND  FEMALE.     In  one  octavo 


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TAYLOR  (SEYMOUR).  INDEX  OF  MEDICINE.  A  Manual  for  the  use  of  Senior 
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THOMAS  (T.  GAILLARD)  AND  MUNDE  (PAUL  F.).  A  PRACTICAL 
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THOMPSON  (SIR  HENRY).  CLINICAL  LECTURES  ON  DISEASES  OF 
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Coleman 

1  Manual  ofdental^ 


'^3"ual  of  dental  suraerv  ann  n^thoioov 

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2002449625 


